Greene, Sophia B. Body Image Perceptions, Interpretations and Attitudes

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS
BODY IMAGE: PERCEPTIONS,

INTERPRETATIONS AND ATTITUDES
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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS
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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS
BODY IMAGE: PERCEPTIONS,

INTERPRETATIONS AND ATTITUDES
SOPHIA B. GREENE
EDITOR
Nova Science Publishers, Inc.

New York
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LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Body image : perceptions, interpretations and attitudes / editor, Sophia B.
Greene.
p. cm.
Includes index.
ISBN 978-1-61122-397-2 (E-Book)
1. Body image. 2. Body image--Psychological aspects. 3. Body
image--Social aspects. I. Greene, Sophia B.
BF697.5.B63B633 2010
155.9'1--dc22
2010041283
Published by Nova Science Publishers, Inc. New York

CONTENTS
Preface vii
Chapter 1 An Historical Perspective of Body Image and Body Image Concerns
among Male and Female Adolescents in Japan 1
Naomi Chisuwa and Jennifer A. ODea
Chapter 2 Body Image Among Aboriginal Children
and Adolescents in Australia 27
Renata L. Cinelli and Jennifer A. ODea
Chapter 3 The Psychology of Body Image: Understanding Body Image
Instability and Distortion 59
Jennifer S. Mills, Kaley Roosen and Rachel Vella-Zarb
Chapter 4 Measurement of the Perceptual Aspects of Body Image 81
Rick M. Gardner and Dana L. Brown
Chapter 5 Body Image and Cancer 103
zen nen Sertz
Chapter 6 Beyond the Media: A Look at Other Socialisation Processes that
Contribute to Body Image Problems and Dysfunctional Eating 121
Marion Kostanski
Chapter 7 Alexithymia, Body Image and Eating Disorders 135
Domenico De Berardis, Viviana Marasco, Daniela Campanella,
Nicola Serroni, Mario Caltabiano, Luigi Olivieri, Carla Ranalli,
Alessandro Carano, Tiziano Acciavatti, Giuseppe Di Iorio,
Marilde Cavuto, Francesco Saverio Moschetta and
Massimo Di Giannantonio
Chapter 8 A Meta-Analytic Review of Sociocultural Influences on Male Body
Image 153
Bryan T. Karazsia and Kathryn Pieper
Chapter 9 Touch and Body: A Role for the Somatosensory Cortex in
Establishing an Early Form of Identity (Review Article) 173
Michael Schaefer
vi Contents
Chapter 10 Nothing Compares to You: The Influence of Body Size of Models

in Print Advertising and Body Comparison Processes on Womens
Body Image 189
Doeschka J. Anschutz, Tatjana Van Strien, Eni S. Becker and
Rutger C.M.E. Engels
Chapter 11 Body Image in People of African Descent: A Systematic Review 203
D. Catherine Walker
Chapter 12 Low SES Childrens BMI Scores and their Perceived and Ideal
Body Images: Intervention Implications 215
Simone Pettigrew,Melanie Pescud and
Robert J. Donovan
Chapter 13 Theoretical and Methodological Considerations in Assessing Body
Image Among Children and Adolescents 227
Margaret Lawler and Elizabeth Nixon
Chapter 14 Issues Pertaining to Body Image Measurement in Exercise Research 245
Rebecca L. Bassett and Kathleen A. Martin Ginis
Chapter 15 Negative Body Image Perception and Associated Attitudes
in Females 255
Tamara Y. Mousa and Rima H. Mashal
Chapter 16 Body Image in Young and Adult Women with Physical Disabilities 263
Nancy Xenakis and Judith Goldberg
Chapter 17 The Non Satisfied Patient in Aesthetic Surgery - Medical Attitude 269
Alberto Rancati, Maurizio Nava, Marcelo Irigo and
Braulio Peralta
Index 275
PREFACE
Body image is considered a multi-dimensional concept that includes perceptual,

attitudinal, affective, and behavioral dimensions. The definition of body image is the mental
picture we have in our minds of the size, shape and form of our bodies and our feelings
concerning these characteristics and one's body parts. This book presents topical research data
from across the globe in the study of body image, including understanding body image
instability and distortion; body image and cancer patients; the advertising media and its
contribution to body image problems and dysfunctional eating; alexithymia, body image and
eating disorders; sociocultural influences on male body image; body image research in people
of African descent; and body image measurement in exercise research, in women with
physical disabilities, and in patients undergoing plastic surgery.
Chapter 1 - This review describes the body image, body image concerns and factors
influencing body image disturbance amongst Japanese adolescents and compares the
historical prevalence and trends with those of Westernized countries. Body image concerns
are now a concerning issue in contemporary Japanese society as they also become a more
global issue. Several reports from other Asian and non-Western countries including Japan
have increasing rates of body image concerns. As body image concerns are related to societal
norms, culture and ethnicity, their study requires an understanding of body image disturbance
within different cultural contexts. Although considered less prevalent than in the West, Japan
has an early history of body concerns and also eating disorders. The reported studies and
trends outlined in this review suggest that, as in Western countries, the interest in and study of
body image concerns and eating disorders in Japan have increased over the last three decades.
The authors also report on the findings of some new qualitative interviews conducted among
male and female Japanese adolescents and some of these unique findings are presented in this
chapter.
Chapter 2 - In the next decade, levels of obesity, body image concerns and dissatisfaction
are expected to continue to escalate in tandem for children and adolescents, including those
from diverse ethnic backgrounds. Holt and Ricciardelli concur that there is increasing
evidence of weight and muscle concerns that include body dissatisfaction along with problem
eating. This is an alarming trend because it has a vast array of health implications for young
people including physical, cultural, social and mental health consequences. Young people
who are overweight and obese in modern Westernized societies are often stigmatized and
ostracized, and overweight adults are known to suffer various forms of discrimination. Body
image concerns are associated with overall poor self concept in early adolescents, including
viii Sophia B. Greene
poor physical, social and academic self concepts as well as low overall self esteem. Further to
that people with poor body image are known to be susceptible to dieting which can lead to
eating disorders. The adverse outcomes of poor body image among children and adolescents
suggest an urgent need for these issues to be addressed in both health and educational
settings.
Owing to the plethora of studies surrounding adolescent and adult females body image,
it is known that dissatisfaction and a preoccupation with unrealistic thinness is entrenched
among many women. This is particularly true of Caucasian, upper class women. Whilst the
trends become less prominent when focusing on males, there is recent evidence from the
literature that societal body image pressures are also reaching men, adolescents and children
as young as five years old.
Moreover, whilst there is a lack of data on minority populations, it has been shown that
the desire for the perfect Westernized body may permeate traditional cultures, such as
Pacific Islander populations and the Indigenous Aboriginal population of Australia. Further,
whilst it is known that higher proportions of Indigenous Australian adolescents are
overweight than their non-Indigenous counterparts, McCabe and colleagues recognise that
little is known about the associated behaviours and attitudes. This underrepresentation needs
to be addressed in order to redress some of the health and education inequities facing the
Indigenous Australian population.
It is well known that body image perceptions are influenced by a variety of sociocultural
factors, including the media, family and peers. It has also been identified that for African
Americans, the influence on body image perceptions of parents and family is greater to that of
Caucasians for whom peer influence appears to be greater. Similar to the findings of Parnell
and colleagues, Cinelli and ODea found that for Indigenous Australian adolescents, the
influence of parents through advice and feedback was a prominent factor in determining
adolescents body image. This could be attributable to the strong family ties and kinship of
Aboriginal culture.
Chapter 3 - In this chapter we consider the psychology of body image and analyze the
concepts of body image instability and body image distortion. Rather than representing a
stable or static trait, we propose that body image is in constant flux, continuously shifting as a
result of factors both internal and external to the individual. We review the literature
supporting the view that peoples perceptions of the size and/or shape of their bodies are not
fixed. Drawing from published empirical studies, including research on personality, the
effects of exposure to media images, social norms, and weight-related feedback, determinants
of body image will be reviewed and critically examined. As a corollary to the concept of body
image malleability, it is further proposed that people tend to be inaccurate when assessing
what their bodies look like. Much of the research to-date on body image distortion has
focused on individuals with clinical eating disorders who exhibit extreme body image
distortion (e.g., anorexia nervosa). Such individuals typically believe that their bodies are
much heavier than they really are. However, even individuals without clinically significant
disorders are often poor at recognizing the size and shape of their own bodies. Interestingly,
people tend to underestimate their weight (in lb or kg), whereas they tend to overestimate
their body size. Possible reasons for this discrepancy in body image accuracy findings are
discussed. In summary, people generally exhibit what we call poor body acuity. There is
little evidence of perceptual dysfunction underlying body image inaccuracy and distortion.
Preface ix
However, certain perceptual influences (i.e., attentional biases) appear to exacerbate poor
body acuity.
Chapter 4 - Body image disturbance (BID) is an important aspect of several pathologies
in psychology, particularly eating disorders. BID is commonly thought to include two
components; a perceptual component and an attitudinal component. The perceptual
component refers to how accurately individuals perceive the size of their body, also known as
body size estimation or BSE. The attitudinal component refers to the thoughts and feelings
one has about the size and/or shape of their body, which is also known as body
dissatisfaction. While both components have been shown to play an important role in eating
disorders, they are largely independent of each other. This chapter reviews the clinical
relevance of measuring BSE in relation to eating disorders and provides an overview of
research findings. A broad historical overview is provided that highlights the various
techniques that have been developed to assess BSE including analogue scales, image
marking, optical distortion methods, and figural drawing scales. Analogue scales require
participants to adjust the horizontal distance of a pair of calipers or two points of light to
show the width of various body parts. Image marking procedures require participants to draw
their body on a vertically mounted piece of paper or to mark on the paper the width of certain
body parts. Recent optical distortion methods typically employ computer software that
presents the participant with an image of themselves that has been distorted in width and
participants are asked to adjust the image to match both the actual and ideal size of their body.
These images are typically static digital images, although photographs have occasionally been
used as well. Each method is discussed along with any relevant limitations or methodological
concerns. Psychophysical techniques such as the method of constant stimuli, signal detection
theory, and adaptive probit estimation are described in relation to methodological concerns
such as distinguishing sensory from non-sensory components of BSE. Video distortion
techniques that incorporate psychophysical techniques appear to be the most precise for
measuring BSE.
Chapter 5 - The diagnosis and treatment of cancer can result both physical and
psychiatric morbidity. Physical and psychological changes during the course of cancer may
alter an individuals body image. Alterations in body image can contribute to the psychosocial
adjustment of cancer patients. Early studies investigating the role of body image among
cancer patients primarily have paid attention to breast cancer patients. The ongoing studies
than examined body image disturbances and factors associated with body image changes in
patients with different types of cancer.
In general factors related to body image changes in cancer patients are due to: 1) cancer
treatments (chemotherapy, radiation therapy, hormone therapy and surgery); 2) results of
treatments such as hair loss, weight loss or weight gain, loss of an organ, scars; 3)
psychological distress related to cancer diagnosis, its treatments and cancer related issues; 4)
personality properties (those who place importance on their appearance are more likely to
experience distress when faced with a greater self-discrepancy in their appearance; 5) gender
(women are more prompt to have more concerns than men about physical appearance; and 6)
age. In addition to all these factors there is literature knowledge that body image concerns can
change in follow-up period of a cancer diagnosis.
In this chapter, body image disturbances in cancer patients, factors related to body image
disturbances, body image disturbances in different types of cancer, impact of body image
x Sophia B. Greene
disturbances on quality of life and sexuality will be discussed. Also treatment approaches for
body image disturbances in cancer patients will be reviewed in the light of the literature.
Chapter 6 - The activities of shopping for clothes and dressing oneself are a major
component of our everyday lives. As noted by Goffman, a large portion of our social
recognition and engagement centres on the preliminary assessment we make of others
presentation and external cues. Extending on this theory, it is argued that ones experience
and beliefs around the act of dressing, and particularly purchasing clothes, will have a strong
influence on how one feels about, and engages with, their body. Through a series of
interviews and the development of a self report inventory, the current research offers an
evaluation of the impact that these activities have on young womens psychosocial wellbeing
and health. Outcomes of both quantitative and qualitative research indicated that over 40% of
the variance in reported experiences was explained by four primary factors; social
engagement, self identity processes, use of popular media such as fashion magazines, and
emotional affect.
As predicted, shopping for clothes was identified as an important personal and social
activity for many participants. Reliance on popular media for informed choice, updates on
trends and knowing what was important was also strongly endorsed. Of significance was the
prevalence of reported negative affective experiences in relation to the experience of
shopping for clothes. Issues such as depressed mood, feeling frustrated, and being
embarrassed to ask for assistance, were consistently reported to be a consequence of this
activity for the women. Affect was found to significantly predict over 30% of the variance
in reported body image dissatisfaction in young women.
The outcomes of this research suggest that there are practical and pragmatic steps that
may alleviate some of the negative experiences. Further the outcomes of this research confirm
that shopping for clothes is imbued with very powerful explicit and implicit messages that
impact strongly on how we feel and perceive ourselves. The underlying dynamic of this
process is a paradoxical dilemma, wherein the women are drawn to engage in a social process
that incorporates both elements of pleasure and necessity and simultaneously struggle with an
internalised attribution style that leaves her with a sense of being personally responsible for
many of the things that go wrong. The research confirms that there are many extraneous
factors that impact on and influence how women perceive and feel about their body. Research
into the development of educational programmes that empower women in articulating and
addressing their experiences of engaging in their world from a non self-deficit perspective
of faulty attributions is recommended.
Chapter 7 - It is widely recognized that the body dissatisfaction and an excessive concern
about body weight and shape are core characteristic of Eating Disorders (EDs) and are used to
determine self-worth. Recently, there was an increased interest about the body image as a
multidimensional issue that involves perceptual, attitudinal and behavioral characteristics.
Many researchers have focused their attention mainly to the perceptual and attitudinal aspects
of body image whereas only few studies have investigated the behavioral consequences
related to a negative body image. Moreover, it is known that alexithymia may play an
important role in EDs: specifically alexithymics patients may show a higher psychological
distress than nonalexithymics and the presence of an alexithymic trait may be related to a
higher severity of EDs themselves. Some core aspects of alexithymic construct, as a difficulty
in distinguishing emotional states from bodily sensations, may be more characterized in
patients with EDs and a possible explanation might be that ED patients may appear
Preface xi
dramatically and deeply incapable of being in touch with their inner emotive world. As
consequence, these subjects may focus their attention on negative perceptual aspects of body
bypassing emotional experiences. Taken together, these findings may suggest that
alexithymia and body image disturbances may be strongly correlated in EDs and, therefore,
the aim of this paper will be to elucidate these relationships along with the presentation of a
clinical study on 64 patients with a DSM-IV diagnosis of anorexia nervosa.
Chapter 8 - Male body dissatisfaction is prevalent and associated with maladaptive
outcomes. Discrepancies exist in this literature concerning the importance of sociocultural
influences on mens body dissatisfaction. The present meta-analysis explored the extent to
which these discrepancies may be related to the way in which constructs are assessed. We
hypothesized that studies that assessed muscularity as a component of sociocultural
influences or mens body dissatisfaction would have larger effect sizes than studies that did
not assess muscularity. Results largely supported this hypothesis; the average effect sizes of
the relationship between internalization and awareness of ideal body figures and mens body
image differed as a function of methodology. When muscularity was assessed, the magnitude
of effect sizes was similar to those reported with female samples. These results have
implications for research and interventions with males.
Chapter 9 - A major cortical representation of our body can be found in the primary
somatosensory cortex (SI). While classic studies understand the body map representation in
SI as fix and reflecting the physical location of peripheral stimulation in the form of the
famous somatosensory homunculus, recent studies challenge this view and suggest a more
complex role for SI. For example, experiments using simple visuo-tactile illusions
demonstrate that SI reflects the perceived rather than the physical location of peripheral
stimulation. Moreover, it has been suggested that SI represents an early concept of our body
that may also include important dimensions of our self. This review reports results of recent
experiments that provide support for this view. For example, SI seems to respond
differentially when observed touch is attributed to the own body compared to another body
(in both cases in absence of any real touch!). Further experiments on observing touch on
others body report that activity in the somatosensory cortex is closely associated with the
personal trait of empathy. Hence, it is proposed that the somatosensory cortices may be
involved in social perception processes and thereby establish first forms of a unique body
image and a personal identity.
Chapter 10 - Associations between body size of print advertising models, body
comparison processes and body-focused anxiety were examined. Normal-weight females
viewed advertisements of slim models, or the same models horizontally stretched to make
them look more average sized. Participants were instructed to focus either on the positive or
the negative features of the models. The results showed that when participants viewed
average sized models, they felt better about their own body, regardless of body comparison
instruction. Interestingly, when participants focused on negative features of the models, they
also felt better about their own body, regardless of body size of the models.
Chapter 11 - In the United States of America, Black people are more likely to be
overweight or obese and are also more likely to suffer from many of the related chronic
diseases. Based on these data, it might be expected that Black men and women would suffer
from greater body image dissatisfaction. However, research suggests that Black women and
Black men are more satisfied with their bodies than are White women and men, respectively.
Historically, research on body image has been conducted using predominantly White female
xii Sophia B. Greene
samples. As a result, it is not clear whether or not the research generalizes to young males,
older men and women, and men and women from different racial and ethnic backgrounds.
The purpose of this chapter is to examine body image research in people of African descent.
Two questions that will be addressed are whether or not body image differs in Black people
compared to research that has been conducted using primarily White participants, and
whether body image has different relationships to variables such as self-esteem, body mass
index (BMI), and eating disorder symptoms in these two groups. In addition, possible reasons
for differences (e.g., mediators and moderators) will be considered.
Chapter 12 - BMI cut-offs were used in conjunction with the Childrens Body Image
Scale to provide a comparison between actual BMI and perceived and ideal body images
among 90 low socioeconomic children aged seven to 10 years. A third of the sample was
classified as overweight or obese, with a higher incidence among boys (38% versus 28% for
girls). Two-thirds underestimated their current body size and only around 5% considered
themselves overweight or obese. Just over 70% selected an underweight ideal body size.
Intervention developers thus face the dual challenge of providing children and their families
with the information and skills they need to prevent childhood obesity while addressing a lack
of awareness of actual body weight among children that is combined with an unrealistic ideal
body size preference. This task is complicated by the need to minimise weight concerns that
can result in eating disorders. The results suggest the need for a family-based approach that
targets parents of young children to increase awareness of healthy body sizes and lifestyle
behaviours before children have become overweight, formed inaccurate weight-related
beliefs, and/or become dissatisfied with their bodies.
Chapter 13 - Body image dissatisfaction, a prevalent concern among children and
adolescents, has been identified as a significant risk factor in the onset of eating pathology,
depression and low self-esteem. Given the negative implications of body image
dissatisfaction, it is important to examine how body image is currently conceptualized and
measured. This chapter proposes to explore theoretical and methodological issues
underpinning the assessment of body image dissatisfaction among children and adolescents.
Careful consideration of the assessment of body image dissatisfaction is further warranted in
light of emerging literature which highlights important gender differences in body appearance
concerns. While an ultra-thin body ideal is emphasized for females, the male appearance ideal
endorses a muscular physique characterised by broad shoulders and a well developed chest.
As such, girls typically demonstrate a drive for thinness, while boys endorse a drive for
muscularity. Empirical findings support this position, demonstrating that girls are most
satisfied with their bodies at below average levels of adiposity, with dissatisfaction increasing
with increased body mass. For boys however, body dissatisfaction is reflected in a desire
among some to lose weight, and a desire among others to gain weight and become more
muscular (McCabe & Ricciardelli, 2004). Such gendered body image patterns have important
implications for the assessment of body image dissatisfaction. Indeed, concerns have been
raised that commonly used measures of body image dissatisfaction solely address ones desire
to be smaller or thinner, which is a predominantly female concern. Specifically, it has been
argued that the figural rating scales may produce a conceptual bias by manipulating adiposity
only, therefore confounding body mass with muscularity. This may be of theoretical
consequence for males who aspire to a muscular ideal. Questionnaire measures have also
been criticized due to their failure to identify the direction of body discontent (desire to be
bigger versus smaller), which may lead to the underestimation of body dissatisfaction among
Preface xiii
males. In light of these important gendered patterns, this chapter will review the conceptual
frameworks and strengths and limitations of existing methods of assessing body
dissatisfaction among children and adolescents.
Chapter 14 - Recent meta-analyses have established a positive relationship between
exercise and body image. However, further research is necessary to answer numerous
remaining questions regarding the relationship between exercise and body image. For
example, the mechanisms by which exercise interventions improve body image are not well
understood. Likewise, characteristics of the most effective exercise programs for enhancing
body image remain unknown. Future research should aim to understand such ambiguities
regarding the exercise-body image relationship. In order to maximize the impact of future
exercise research, proper measurement of body image is critical.
Several important considerations for the measurement of body image were highlighted in
an article by Thompson [2004]. In the current commentary, Thompsons article is used as a
framework for discussion of issues pertaining to body image measurement specifically with
regard to exercise research. Five considerations are addressed: 1] Defining the specific
dimension of body image being considered and measure accordingly. 2] Considering multiple
measures of body image. 3] Selecting valid and reliable body image measures. 4] Considering
sample characteristics. 5] Considering the appropriateness of state or trait body image
measures. The commentary will serve as a useful guide for proper measurement of body
image within exercise research.
Chapter 15 - Negative body image perception has predisposed females, particularly
adolescent and young females, to be more preoccupied with their body image than males.
This has been explained by the perception of female beauty with extreme thinness. Western
females are preoccupied with their body image due to social and cultural norms that
emphasize on thinness, which is internalized as a symbol of success. Furthermore, beauty
Western ideals have recently been found to influence body image perception of Arabic
females through mass media. Negative body image perception has been indicated to
contribute to body image dissatisfaction. Because females are concerned about their body
image and weight, they tend to correct imperfections through engaging in negative eating
attitudes and behaviors. It has also been documented that body image dissatisfaction is
associated with acknowledging eating disorders, increasing the risk of exhibiting health
compromising behaviors. In all, well-controlled prospective studies on negative body image
perception and the factors associated with it are encouraged. Research should also attempt to
develop intervention programs to improve body image of females.
Chapter 16 - Recent literature has shown that women with physical disabilities often face
physical and emotional barriers to their own health and wellness. Persons with disabilities are
often seen as others in relation to the general population. Attitudes toward people with
physical disabilities are generally negative, simplistic and discriminative. Moreover, women
with a physical disability must deal with Westernized gender roles and beauty ideals that are
constantly imposed upon them. As a result, this group of women often has difficulty
developing a healthy image of their bodies, socializing and expressing themselves, especially
when compared with their able-bodied counterparts.
In particular, young women, as they reach adolescence, develop a growing awareness of
just how different their bodies are when compared with their able-bodied peers. This
unhealthy self concept is often perpetuated by the perceived influence of various socio
cultural factors such as the media, peers and adult figures regarding thinness and body ideal.
xiv Sophia B. Greene
Their disabilities become imperfections. These young women must also overcome myths that
they are asexual or incapable of handling sexual relationships. Physicians can also reinforce
these myths by infantilizing these young women with physical disabilities well into adulthood
though many have aspirations of marriage and motherhood.
People with disabilities have become increasingly able to live fulfilling lives in recent
decades. This is due largely to studies that have confirmed that once barriers are addressed
and minimized; women with physical disabilities lead active and productive lives and have
much to contribute to society. American with Disabilities Act legislation has allowed more
women with disabilities to enter the mainstream environment socially, educationally and
vocationally. The involvement of professionals, programs and services assists these women to
increase their self-confidence, self-competence and independence.
The Initiative for Women with Disabilities (IWD), a hospital-based center serving young
and adult women with physical disabilities offers accessible gynecology, primary care,
physical therapy, nutrition consultations, exercise and fitness classes, wellness and social
work services and youth based programming. Its mission is to empower women to pursue a
healthy lifestyle.
Chapter 17 - Usually, patients undergoing plastic surgery have only the expectation of
success about the practice they will undergo, and on the same way, surgeons are prepared and
technically trained to achieve the better result. But what happens when things go wrong?
How can we manage this critical situation where patient receives this bad news and will
probably blame the surgeon for this unexpected outcome?
Elective cosmetic surgery is an increasingly high risk area of medical professional
liability, and, although some claims of negligence associated with elective plastic surgery are
generated because the patient's expectations were not met, others arise from a genuine
adverse outcome where results need revisions, and perhaps surgical planning was not the
best.(1),(2).
Unfortunately sometimes this narrow limit between an adverse event and a medical error
is forced to be seen as malpraxis by lawyers, family patients and friends.
In: Body Image: Perceptions, Interpretations and Attitudes ISBN 978-1-61761-992-2
Editor: Sophia B. Greene 2011 Nova Science Publishers, Inc.
Chapter 1
AN HISTORICAL PERSPECTIVE OF BODY IMAGE AND

BODY IMAGE CONCERNS AMONG MALE AND
FEMALE ADOLESCENTS IN JAPAN
Naomi Chisuwa1 and Jennifer A. ODea2*

1
Bachelor of Human Life Science; MSc
2
Faculty of Education & Social Work
University of Sydney, Australia
ABSTRACT
This review describes the body image, body image concerns and factors influencing
body image disturbance amongst Japanese adolescents and compares the historical
prevalence and trends with those of Westernized countries. Body image concerns are now
a concerning issue in contemporary Japanese society as they also become a more global
issue. Several reports from other Asian and non-Western countries including Japan have
increasing rates of body image concerns. As body image concerns are related to societal
norms, culture and ethnicity, their study requires an understanding of body image
disturbance within different cultural contexts. Although considered less prevalent than in
the West, Japan has an early history of body concerns and also eating disorders. The
reported studies and trends outlined in this review suggest that, as in Western countries,
the interest in and study of body image concerns and eating disorders in Japan have
increased over the last three decades. The authors also report on the findings of some new
qualitative interviews conducted among male and female Japanese adolescents and some
of these unique findings are presented in this chapter.
*
Author for correspondence:
A/Prof Jennifer A. ODea
Faculty of Education & Social Work
Room 911, Building A35, NSW, 2006
Australia
Tel 61-2-93516226
Fax- 61-2-93512606
Email: j.odea@edfac.usyd.edu.au
2 Naomi Chisuwa and Jennifer A. ODea
INTRODUCTION
This review will describe the prevalence of body image concerns amongst Japanese
adolescents with a particular focus on prevalence of body dissatisfaction in Japan, public
health problems related to body image disturbance, and possible factors influencing body
image disturbance among male and female adolescents living in contemporary Japanese
society.
Body dissatisfaction, dieting, eating disorders, exercise disorders and other health
damaging body image related behaviors such as excessive weight lifting, body building and
steroid abuse are prevalent among male and female adolescents and young adults worldwide
(Garman, Hayduk, Crider & Hodel, 2004; Racette, Deusinger, Strube, Highstein &
Deusinger, 2005). Given the increasing public health risks associated with body image
concerns and the long term cost, severity and difficulty of treating eating disorders,
prevention of these problems is a well-recognised health education goal.
BODY IMAGE DISTURBANCE

Body image disturbance has grown in prevalence and as such is now a major threat to
adolescent health in Westernised countries worldwide (Paxton, 2000). Of the many aspects of
body image disturbance, body dissatisfaction is a particular target issue for adolescent health
practitioners with approximately 60% of females and 30% males in the USA identified as
sufferers (Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002). Adolescents who have
body dissatisfaction typically engage in unhealthy behaviors, such as dietary restraint, use of
diet pills and obsessive exercise. These are also known predictors for being overweight or
obese, and for eating disorders such as anorexia nervosa and bulimia nervosa (Littleton &
Ollendick, 2003). In addition, body dissatisfaction is also linked with mental disorders
including depression and anxiety amongst this group (Stice & Whitenton, 2002).
Body image research from around the world, which began in the 1980s, has dramatically
increased in line with the growing awareness a negative body image has as one of the key
factors contributing to eating disorders (Grogan, 2008). A substantial number of these studies
show that the type and degree of body image disturbance varies according to factors, such as
gender, age, ethnicity, peers, family, personal experiences and socio-cultural influences
(O'Dea, 2008; Ricciardelli & McCabe, 2003; Stice & Whitenton, 2002). These studies
suggest that the risk is greatest among women within the Western cultural context (Pate,
Pumariega, Hester, & Garner, 1992) and perhaps less so for those in a non-Western context,
though this outcome is due more to lack of relevant studies rather than any research
conclusions.
BODY IMAGE STUDIES IN JAPAN

A summary of the findings from body image studies in Japan and other countries is given
below in Table 1. Young Japanese women of all weight categories tend to overestimate their
body image (Saito, 1997; Mukai, 1998; Yates, 2004; Wardle, 2006), whereas self-evaluation
Historical Perspective of Body Image and Body Image Concerns in Japan 3
in males is generally accurate (Ministry of Health Labour and Welfare, 2004; Yamamoto et
al., 2007).
Table 1. Comparison of findings from studies of body image among Japanese young
people and those from other countries
Sample
Study (Japanese) Age Major findings
Saito et al. (1997) 138 (males), undergraduate Ideal self image of Japanese males was
*comparison 130 significantly poorer than that of Australian
with Australians (females) males.
Japanese females were more likely to
describe themselves as bigger than
Australian females.
Mukai et al. 171 20.2 (mean) Japanese females showed greater body
(1998) (females) dissatisfaction compared to that of
*comparison American females.
with Americans BMI was not a significant predictor of
eating disorders for Japanese females.
The need for social approval predicted
eating disorders in Japanese females.
Yates et al. 68 (males), undergraduate BMI was highly correlated with body and
(2004) 87 self satisfaction, but there were significant
*comparison (females) ethnic differences in body image.
with White, Japanese females were highly dissatisfied
African- with their body and self although they
American, were relatively small.
Chinese,
Hawaiian
Shih et al. (2005) 144 20.2 (mean) Japanese females showed lower body
*comparative (females) satisfaction than Taiwanese females.
study with
Taiwan
Wardle et al. (18,512 17-30 Perception of being overweight and

(2006) participants) attempts to lose weight were highest
*comparison amongst Asian participants regardless of
amongst 22 the current body weight.
countries Japanese showed the highest prevalence
of perceived overweight.
Studies summarized in Table 2, below, show that 41% and 68% of Japanese female
adolescents aged 6-13 years and 16-18 years respectively had negative body image perception
and high desire for thinness, regardless of their actual weight (Ohtahara, Ohzeki, Hanaki,
Motozumi, & Shiraki, 1993). Consistent with the findings by Ohtahara et al (1993), Kaneko
et al. (1999) also report similar findings, that many Japanese girls had weight and shape
concerns. Similarly, as this trend of overestimation has grown in most female age groups
since 1998, it is considered that body image perception amongst Japanese females has
become distorted (Hayashi et al., 2006). Consistent with the findings of these studies of a
distorted body image amongst Japanese females, groups of underweight girls, normal girls
and normal weight boys tended to regard their actual physiques as rather broad,
demonstrating that many girls and boys are excessively preoccupied with thinness (Nishizawa
et al., 2003).
Table 2 Summary of studies reporting on body image, dieting, disordered eating and
unhealthy eating behaviors in Japanese adolescents and young adults between
1994 and 2006
Study Sample Age Major findings
Ohtahara et al. 130 (boys), 6-18 41% and 68% of the girls in elementary
(1993) 125 (girls) school and high school respectively
perceived their ideal weight to be less
than the normal weight.
Most boys were likely to want to gain
weight.
Mukai et al. (1994) 197 18.9 (mean) 60% of females had experiences of
(females) occasional binge eating. 15% of females
ocassionally vomited.
Nakamura et al. 406 27.9 (mean) 42.4% (dieting experiences), 5.9%

(1999) (females) (fasting experiences), 14.3% (used diet
pills), 10.3% (laxative abuse), 3.7%
(diuretic abuse).
Kaneko et al. 709 (boys), 10-17 48% of 10-year-old girls and 84% of 17-
(1999) 923 (girls) year-old girls described themselves as
"fat" or "too fat".
32% of girls who were thin and 14% of
girls who were very thin were also
trying to lose weight.
22% of 10- year-old girls and 37% of
17-year-old girls had dieting
experiences, whereas 20% of boys at
each age had dieting experiences.
Table 2 (Continued)

Nishizawa (2003) 1,128 (both) 15-17 Girls showed greater desire for thinness
than boys.
Desire for thinness and eating problems
were strongly correlated in both boys
and girls.
National Nutrition 301 (males), 15-19 70.9% and 17.9% of females who were
Survey in 2002 314 "normal weight" and "underweight"
(2004) (females) perceived themselves as "fat".
24.1% and 64.1% of males and females
were trying to lose weight regardless of
their current weight.
40% of females who were underweight
were trying to lose weight.
Suka et al. (2006) 2,452 (boys), 12-13 34.2% of girls described themselves as
2,792 (girls) fat. 58.0% of girls showed a desire for
thinness.
Boys tend to have a positive body image
as they get older, whereas girls tend to
have a negative body image.
5.7% and 17.3% of boys and girls had
dieting experiences.
Yamamoto et al. 263 (boys), 13.9 (mean) 7% of girls and 3% of boys showed
(2007) 220 (girls) clear indications of abnormal eating
behavior.
Girls had a significant gap between
current body image and ideal body
image, while boys did not have a
significant gap between them.
Kagawa et al. 84 (males), 20.5 (mean) Females showed a significantly greater
(2007) 139 desire for thinness than males.
(females) Females tended to overestimate their
body shape, whereas males tended to
underestimate their body shape.
National Nutrition 263 (males), 20-29 Regardless of their current weight,
Survey in 2008 294 31.8% and 55.8% of females are trying
(2009) (females) to lose weight.
Desired BMI in females was 19.0.
Literature tends to confirm that a significant number of Japanese adolescents have some
degree of body image disturbance from early adolescence and in particular, girls are at an
unusually high risk. Ohtahara et al. (1993) found that 30% of girls aged 6 years showed
distorted body image perception, body dissatisfaction and a desire for a thin ideal. According
to Suka et al. (2006), girls aged 10-17 years perceived themselves as average or too fat
(60.9%), wanted to be thinner (24.5%) and had tried dieting (7.5%) Boys showed lower rates
across all of these three body image categories. Interestingly, those who perceive themselves
as fat are not always consistent with those who are actually overweight, and this is
particularly true among girls.
It is notable that across all the cited research, most studies report on cultural influences on
female body image disturbance and there are few studies about male body image concerns. In
a review of studies about the role of ethnicity and culture in body image and disordered eating
among males, Riccardelli et al. (2007) reported that evidence on Asian male body image
concerns was inconsistent and still unclear.
In Japan, Ortahara et al. (1993) reported that male adolescents want to gain weight. Suka
et al. (2006) found that body satisfaction in males increased due to gained muscularity as they
became older. In addition, and more recently, Kagawa et al. (2007) found that males tend to
underestimate their body weight and that they want to be bigger, suggesting that current
results may not accurately reflect body dissatisfaction, as many young males are also known
to be obsessed with exercise and unhealthy eating behaviors (O'Dea & Yager, 2006). The
underestimation of body shape and size and subsequent body dissatisfaction in Japanese
males therefore needs to be further explored to examine these phenomena from a cultural
perspective.
There are some limitations of body image studies in Japan. Although some researchers
reported similar overall results, the use of various and inconsistent instruments, limits the
comparison of the results. Moreover, most of the published Japanese studies used self-
reported weight and height to calculate BMI, which has been found to be inaccurate in some
cases (Urata, Fukuyama, & Tahara, 2001). The appropriate instruments need to be
standardized to accurately examine body image amongst Japanese adolescents. In addition,
the emergence of a relationship between body image disturbance and eating related problems
is not reported. Further studies are required to confirm the findings from studies within
Japanese adolescents and contrast with those conducted in Western countries.
COMPARATIVE STUDIES ABOUT BODY IMAGE DISTURBANCE

With the high emergence of eating related problems, the recognition towards cultural
difference of body image has been increasing dramatically as each culture has different idea
of body image (Grogan, 2008; Smolak & Striegel-Moore, 2001). There is a need for
additional studies to differentiate between different cultural groups among Asians, which is
rarely done (Ricclardelli, McCabe, Williams, & Thompson, 2007). Although studies
conducted among the Japanese population are still few, some comparative studies have been
conducted between Japanese participants and Asian populations or those from other countries.
Although a thin ideal body image has been confirmed mainly within Westernized
Caucasian females, there were no cultural differences of body shape perception and ideal
body shape for males and females amongst university students in Australia with Northern
European, Southern European and Asian background (O'Dea, 1999). In addition, this
Australian study found that among underweight young women there was no cultural
difference in body size preference with most young women desiring a slim ideal and 42
percent desiring weight loss (O'Dea, 1998). These results confirm that young women living in
Western countries aspire to the thin ideal regardless of their cultural background.
In the study conducted by ODea (1999), Asian males and females had significantly
higher rates of underweight than participants from Caucasian, Northern European or other
backgrounds (28.1% and 55.2%). Interestingly, Asian males and females wanted to be bigger
compared to Europeans. Considering that the participants were living in the same
Westernized cultural settings, the results also imply that Asian students are more susceptible
to body image concerns than their European peers (O'Dea, 1999).
Saito et al. (1997) as cited in Table 1, showed that Japanese female students had a
significantly bigger body image discrepancy between their actual-self and their ideal-self
when compared to Caucasian female students in Australia (Saito, O'Dea, O'Brien, & Tazaki,
1997). Although there was a difference in male body image between Japanese university
students and Australian students, the results were not considered significant as their
perceptions reflected their actual body shape and analysis of their height and weight showed it
largely reflected what they had described (Saito et al., 1997).
The Japanese discontent with body image was also confirmed in an international survey
on University students across 22 countries conducted by Wardle et al. (2006). In that study,
Japanese male and female students showed the highest incidence of perceived overweight
and trying to lose weight for each gender. Overall, Asian populations (Japanese, Korean
and Thai) had negative body image and a higher incidence of weight control compared to
other countries. Furthermore, Yates et al. (2004) found that after combining each Asian sub-
group or country based group into a single category denoted as Asian, significant cultural
differences of body image became less prominent, suggesting that there are distinct Asian
ethnic subgroup differences in body image and weight disturbance (Wardle, Haase, &
Steptoe, 2006).
Yates et al. (2004) compared BMI and body/self-dissatisfaction among male and female
college students of seven different ethnicities living in Hawaii (White, Japanese, African-
American, Filipino, Chinese, Hawaiian, and multiethnic). They showed that, regardless of
ethnic and gender differences, BMI was highly correlated with body and self-dissatisfaction.
Only Japanese females did not follow this trend. Instead, Japanese females showed low BMI,
high body dissatisfaction, and the highest self-dissatisfaction score of any group, male or
female (Yates et al., 2004).
Consistent with this result, Mukai et al. (1998) also revealed that BMI was a significant
predictor of eating disturbances for American women, but that this did not apply for Japanese
women with the latter displaying greater body dissatisfaction but no more eating disturbances
than American women (Mukai, Kambara, & Sasaki, 1998). Similarly, comparison within
Eastern countries shows that Japanese female students have higher body dissatisfaction than
Taiwanese female students and the Japanese also rate themselves as larger despite no
significant difference in BMI (Shih & Kubo, 2005).
It should be noted that there are some limitations in those comparative studies, mainly
due to the low number of subjects and the lack of detailed cultural explanation towards body
image disturbance for Japanese adolescents. However, results from comparative studies still
indicate that the culturally entrenched thin ideal amongst Japanese adolescents is well known
and consistently recorded.
Table 3. Socio-cultural factors identified as influencing body image and eating problems among Japanese Adolescents and young people
Mukai et al. 897 (females) 13-16 Maternal factors were as stronger than peer influence in grade8 and 9 girls,
(1996) (Grade7-11) whereas the opposite tendency was seen in girls in grade 10 and 11.
Peers had a greater impact on their dieting behaviors as they got older.
Mukai et al. 171 (females) 20.2 (mean) The need for social approval predicted eating disorders in Japanese females.
(1998)
Kowner (2002) 273 (males), 20 (mean) Body esteem is positively related to self-esteem and body consciousness, and negatively to
332 (females) social anxiety for both genders.
Kowner (2004) 143 (males), 20.7 (mean) Low body satisfaction is caused by a discrepancy between perceptions of actual boy shape
120 (females) and the ideal self as well as to self-esteem and a predisposition to interpersonal phobia.
National 301 (males), 15-19 42.3% and 65.8% of males and females described themselves as "slightly fat" or "fat"
Nutrition Survey 314 (females) because of comparison with others.
in 2002 (2004)
Saito (2004) 321 (females) 18-34 The onset of eating disorders amongst Japanese females is influenced by socio-cultural
factors. In particular, the adaptation for social expectation for females leads to low self-
esteem and resulting eating disorders.
Pike et al. (2004) 4 female cases 18-23 The model of Westernization has limited use when explaining the rise of eating disorders in
Japan.
The increase of eating disorders in Japan is related to cultural values, expectations and
pressures regarding the female role in Japanese society.
Table 3. (Continued)
Takimoto et al. 30,903 15-29 Females aged 15-19 living in metropolitan areas showed significantly higher rates for
(2004) (females) classification as thin and extremely thin, compared to those who are living in smaller towns.
Ozawa et al. 973 (females) 20.7 (mean) The prevalence of eating disturbance in females who frequently read magazines was seven
(2005) times as high as that in those who do not read magazines.
Hayashi et al. 1,731 15-39 Females living in metropolitan areas showed a greater drive for thinness compared to those
(2006) (females) who were living in smaller towns.
Yamamoto et al. 263 (boys), 13.9 (mean) There was relationship between abnormal eating behavior and individual psychological
(2007) 220 (girls) complaints, current and ideal body image and low self-esteem.
Yamamiya et al. 289 (females) 19.9 (mean) Body image and eating disturbance amongst Japanese females were significantly influenced
(2008) by socio-cultural factors, such as peer, media and family.
Nakamura (2008) 2,242 (both) 10-15 Adolescents living in a big city were more likely to have unhealthy eating behaviors
compared to those living in smaller towns.
FACTORS ASSOCIATED WITH BODY IMAGE DISTURBANCE AND

EATING RELATED PROBLEMS AMONGST JAPANESE ADOLESCENTS
There has been some research looking more closely at body image differences between
Japan and other countries and the various factors influencing body image and all studies
related to the topic have been summarized in Table 3. Kowner (2002) investigated Japanese
body image from a cultural perspective, focusing on body esteem. He found that the Japanese
identified similar characteristics of body esteem as these cited by Americans, which mainly
consisted of physical and sexual attractiveness (Kowner, 2002).
However, both male and female Japanese body esteem scores were significantly lower
than those of Americans, Chinese and Israelis (Kowner, 2002). This result indicates that
Japanese body image may have a peculiar dimension shaped by Japanese society.
The study of Kowner (2002) also explained lower body esteem amongst Japanese in
terms of self-effacement, lower self-esteem and body consciousness and greater social anxiety
compared with those in Western countries (Kowner, 2002, 2004). These are thought to stem
from broader cultural and historical perspectives in Japanese society, which has experienced
high incongruence between Western-oriented culture and Japanese traditional culture
(Kowner, 2004).
Furthermore, Pike et al. (2004) using case studies of qualitative interviews, described
some specific features of Japanese society correlated with eating disorders. Data suggest that
the model of Westernization which is suggested as a factor in the development of body
dissatisfaction and eating disorders has limits in adequately explaining the idea that young
Japanese are attempting to fulfill traditional gender roles in the onset of eating disorders.
Although this study did not specifically explore body image in Japanese society, the results
may be extrapolated to suggest that Japanese body image is strongly influenced by such
socio-cultural factors.
In order to explore possible culturally related factors in the development of body image in
Japan, the following literature are reviewed.
Socio-Cultural Factors
Socio-cultural factors have been regarded as the most influential risk factors for body
image disturbance in a substantial number of studies from Japan (Spurgas, 2005; Thompson
et al., 1999). Body image disturbance in Japan is also thought to include some socio-cultural
factors which are peculiar to that specific culture (Pike & Borovoy, 2004; Wardle et al.,
2006).
The tripartite influence model of body image disturbance is a well-known theoretical
model which refers to three influential socio-cultural factors: peers, parents and media
(Thompson et al., 1999). This model also includes two mechanisms; social comparison and
thin ideal internalization, which mediate between these influences (Thompson et al., 1999).
Yamamiya et al. (2008) replicated a study conducted in the USA to examine this tripartite
model using 285 Japanese female university students. The result suggest that socio-cultural
variables have similar influences on body image disturbance to those in the USA and this
model might be applicable to Japanese adolescents (Yamamiya, Shroff, & Thompson, 2008).
However, this study investigated a relatively small number of females in a limited age group.
Confirmatory studies of this result using a larger number subjects and studies including males
are required to examine the applicability of the research to an exclusively Japanese
population.
Peers
Peers have been confirmed as an influential factor on body image amongst adolescents
(Dohnt & Tiggemann, 2006; Hutchinson & Rapee, 2007; McCabe, Ricciardelli, & Finemore,
2002). In Japan, there are few studies to investigate the relationship between peer influences
and body image disturbance and dieting behaviors. Only one study conducted by Mukai
(1994) confirmed peer influence as a factor in the body image development of Japanese
females aged 13-17 years. Supporting this earlier result, a National Nutrition Survey in 2002
(2004) also refers to 65.8% of females aged 15-19 years perceiving themselves as bigger or
fatter when compared with others i.e. peers and the general public.
Media
The media has been recognized as a key antagonist in creating negative body image
amongst adolescents with researchers widely acknowledging that there is a significant
relationship between media exposure and body image disturbance (Tiggemann, 2006). Some
longitudinal studies have identified that exposure to the media predicts negative body image
and the acceptance of the thin ideal as a predictor for problematic eating behaviors (Field,
Camargo, Taylor, Berkey, & Colditz, 1999; Ricciardelli & McCabe, 2003).
In Japan, despite a huge prevalence of media use among adolescents, research about the
impact of it on adolescents falls behind western countries. Recently Ozawa et al. (2005)
conducted a questionnaire survey to investigate the relationship between eating disorders and
exposure to womens magazine that included articles about the thin ideal. The study showed
that most participants often read the magazines and those who often read them tended to have
eating disordered symptoms compared to those who do not read womens magazines (Ozawa,
Tomiie, Miyano, Koyama, & Sakano, 2005).
Family
Family plays a major role in our socio-cultural setting and it has been suggested that
parents who over-protect or over-control their childs eating can contribute to the
development of body image disturbance and eating disorders (Thompson & Smolak, 2002).
Yamamoto et al. (2007) implied that more adolescents in Japan might have the negative
impressions from their family, including inflexibility and distance from the family compared
to previous generations. They also found out that adolescents with a negative impression of
family cohesion and adaptability were more likely to have low self-esteem (Yamamoto et al.,
2007).
In particular, the role of the mother has a significant influence on body image in Japan.
Young adolescents are known to engage in monitoring behavior with their mothers by sharing
weight concerns and dieting behaviors. In addition, young adolescents report expectations
and pressure from their mothers to lose weight or stay thin (Mukai, 1996).
In summary, studies related to socio-cultural factors suggest that Japanese society has a
strong ideal of thinness created by their own cultural values mixed with Western ideals. It is
thought that the media and significant others enhance this culturally bounded issue and that
the mediation of these cultural surroundings reinforces the thin ideal which is embedded
within individuals. This can be used as a framework to understand Japanese adolescent body
image.
Gender Roles
The gender expectations of the female role is recognized as an influential factor in the
desire for the slim ideal and the subsequent body image concerns and resultant eating
problems among Japanese women. This gender influence is confirmed by the predominance
of eating disorders in the female population when compared to rates amongst males (Smolak
& Murnen, 2001). In a society such as Japan, the role of the modern liberated women is still
expected to take a back seat to the role of the female in traditional culture. Women face
conflict in wanting to achieve equality in areas such as the workplace with a more
conservative traditional maternal role (Pike & Borovoy, 2004).
In-line with traditional Japanese norms, self-assertion is regarded as immature or selfish,
and self-praising and self-promotion are recognized as bad manners (Kayano et al., 2008).
Even with the gradual changes happening in regard to gender equality in some facets of
Japanese society, women are still expected to praise men to confirm their higher status over
women in the vertical societal hierarchy. As a result of adherence by most women to this
socio-culturally standardized gender role, women lose self-esteem, self-assertion and the
ability to cope with social issues (Pike & Borovoy, 2004). This low self esteem, expected self
deprecation and high regard for slimness as norms of physical beauty then lead to the onset of
eating disorder symptoms (Saito, 2004).
Personal Factors
Personal traits are other factors that can potentially lead to body image disturbance in
adolescents as both biological and environmental influences cause significant changes in
behavior and mental state. Low self-esteem is a common issue for this age group and this is
known to be strongly associated with negative body image and eating problems (Shroff &
Thompson, 2006).
Kowner (2004) says that Japanese low body esteem amongst Japanese is correlated with
poor self-esteem, body consciousness, and social anxiety. This explanation is consistent with
comparative studies from other Asian countries. Although lower self-esteem may represent
individuals of many collectivist cultures, the scores on body esteem of the Hong Kong were
still higher than Japanese. Low self-esteem is considered to be a common condition amongst
young Japanese (Kowner, 2002). Social anxiety amongst Japanese adolescents is considered a
significant contributory factor in further developing low self-esteem and low body esteem. In
fact, social anxiety is a major mental disorder amongst young adults known as taijin kyofu
sho (interpersonal phobia) with 30% of university students thought to be seeking
hospitalization for it (Nagai, 1994).
Historically, Japanese culture has also been shown to place a strong emphasis on
conformity to social norms and therefore Japanese people may be more sensitive to others
evaluations of themselves, compared to that in Western society (Nogami, 1997). Following
this assumption, Mukai et al. (1998) identified that the need for approval correlated positively
with body dissatisfaction amongst Japanese girls. Personal factors, such as low self-esteem
and social anxiety, appear to be culturally mediated influential factors which worsen the body
image of Japanese youth.
Environmental Factors
It has been proposed that the area of residence may also have an influence on the body
image of young people in Japan. In the recent study of Hayashi et al., (2006) young Japanese
women aged over 15 years living in metropolitan areas show a significantly higher desire for
thinness than women living in smaller cities or smaller towns. Although there was no
significant difference between the overestimation of body size of women living in larger
cities and smaller towns, women living in large cities were more likely to have a distorted
body image.
Similarly, Takimoto et al. (2004) also reported that females aged 15-19 years living in
metropolitan areas were predominantly categorized as underweight compared to those living
in smaller towns. In the same study, adolescents living in a big city were more likely to have
unhealthy eating behaviors in comparison to their peers from smaller towns (Nakamura,
2008). These studies imply that there is a geographical or socioeconomic influence on body
perception, drive for thinness and resulting eating problems among Japanese youth.
OBESITY IN JAPAN AS AN INFLUENCE ON BODY IMAGE

Obesity is one of the most prominent and popular issues in the media in developed
societies and the issue also receives a lot of attention in Japan. From a simplistic clinical
perspective, becoming obese occurs when energy intake exceeds energy consumption, but the
problems around obesity are multi-causal and complex. Binge eating disorder may account
for a significant proportion of obesity cases and hence, obesity is considered a potential risk
factor for acquiring eating disorders and vice versa (Darby, Hay, Mond, Rodgers, & Owen,
2007). Dieting is known to predict weight gain in teenaged girls (Stice et al, 1999; Neumark-
Stzainer et al, 2007)
Research findings have focused public attention on obesity in Japan through health
promotion campaigns. According to the National Health and Nutrition Survey in Japan
(2007), amongst Japanese populations aged over 20 years, the rate of obesity in males and
females was 30.4 and 20.2 respectively. Comparing this to the rate of 20 years prior, the rate
of obesity particularly in the male population has increased significantly (Ministry of Health
Labour and Welfare, 2008). This trend may place an added focus upon weight issues and may
precipitate or worsen body image concerns and the tendency towards eating disorders.
Interestingly, although many health professionals in Japan have been concerned about
rates of obesity particularly amongst males, the prevalence in the female population has
actually been decreasing (Hayashi, Takimoto, Yoshita, & Yoshiike, 2006) with the number of
underweight females increasing significantly in the 20-39 year age group. The prevalence of
underweight in females in their 20s was 25.2% and this proportion of underweight has
increased continually in the past 20 years (Ministry of Health Labour and Welfare, 2008). It is
thought that many young females tend to be thinner due to an extreme desire for thinness and
dieting behaviors and because they have a different ideal body image from young males
(Hayashi et al., 2006; Takimoto, Yoshiike, Kaneda, & Yoshita, 2004). The latest report of the
National Health and Nutrition survey in 2008 also indicated the same tendency still remained
by showing the desired BMI was 19.0 in females aged 20-29 years (Ministry of Health
Labour and Welfare, 2009).
Unfortunately, in Japan, adolescents aged 5-17 years are not included in the National
Health and Nutrition survey and BMI is not used to assess fatness in this age group. Instead,
percent excess overweight has been used as a measure of fatness. It is therefore difficult to
compare how the prevalence of obesity has changed across the generations. Due to the
inconsistent means of the BMI assessment, the prevalence of obesity amongst school children
in Japan has been significantly underestimated (Inokuchi, Matsuo, Takayama, & Hasegawa,
2009). This suggested underestimation has been used to arrive at inaccurate comparisons
suggesting that Japanese adolescents are relatively thin compared to other countries (Murata,
2000).
Research studies conducted in Japan also suggest that normal weight among young
adolescents has also gradually been getting lower over the last two decades. The rate has
changed from 64.0% to 57.0% and from 62.1% to 56.6% in males and females in these 15
years (Ministry of Health Labour and Welfare, 2004). The rates for overweight and obesity
and thin and too thin are increasing. This suggests a tendency towards the two extremities
of weight and a polarization in adolescents body shape that in turn indicates that current
health education programs and campaigns are not working for this group, and that they may
in fact, be working against a healthy, moderate weight paradigm.
EATING DISORDERS IN JAPAN

Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), binge eating
disorder (BED) and eating disorders otherwise not specified (EDNOS) are major and serious
health problems related to body image disturbance amongst adolescents (Thompson &
Smolak, 2002). In Western countries, the rates of AN and BN amongst young females are
reported to be 0.3% and 1% respectively in the general population (Howk & van Hoken,
2003).
Although eating disorders have been previously regarded as peculiar to Western society,
they are now considered a more global issue with some researchers recently confirming that
non-Western countries including Japan, China, Taiwan, Hong Kong, the Republic of Korea
and Singapore (Keel & Klump, 2003) have increasing rates of eating disorders (Mellor et al.,
2008). As the aetiology of eating disorders is strongly related to societal norms, culture and
ethnicity (Keel & Klump, 2003), their study requires an understanding of the issues around
body image disturbance within different cultural contexts.
EARLY REPORTS OF EATING DISORDERS FROM JAPAN

Very early reports of body image concerns and eating disorders were clearly described in
Japan in the medical literature dating as far back as the late 1600s (Kagawa, cited in Nogami,
1997) and these are nicely summarized in a review by Nogami, (1997).
In Nogamis review, Shutoku Kagawa (1683-1755) describes patients with a psychic
illness who would not eat regular rice, but only small amounts of food such as chestnuts or
tofu for several days, months, or sometimes for more than a year. Kagawa wrote that 'they
would always vomit if they were forced to eat' and they showed bradycardia even though they
were not extremely emaciated.
As further reported in the review by Nogami (1997), Kagawa saw 30 patients; most were
women, with male patients numbering only two or three.
Later, observations from Japanese researchers Suematsu" (1985) and Shimosaka" (1986)
agree that Kagawa's description of Fushoku-byo resembles the clinical picture of anorexia
nervosa today. In a later description, Kagawa also describes the case of a nun who avoided
eating for a long period - a close resemblance to the Catholic saints and 'miracle maidens' of
Western countries described by Rudolph Bell, in his book Holy Anorexia (1985).
RESEARCH IN THE LATE 20TH CENTURY

Although considered less in number then in the West, Japan does have a well
documented history of body image concerns and eating disorder research dating back to the
1980s. Following the research trends of Western countries the interest in and study of eating
disorders in Japan increased during the 1980s (Nogami, 1997). The prevalence of eating
disorders in Japan based on reviews, epidemiological studies and clinical reports with the
range of rates for eating disorders ranging approximately from 0.025% to 0.2% for AN and
from 1.9 to 2.9% for BN.
Studies suggest that the prevalence of eating disorders has been increasing significantly
during the past three decades but they also appear to continue to be quite low compared to
those in Western countries (Nogami, 1997; Tsai, 2000).
DISORDERED EATING BEHAVIORS IN JAPAN

Disordered eating and exercising behaviors such as skipping meals, obsessive exercise,
vomiting, and using laxatives or diuretics have been recognized as indicators of body image
concerns and subclinical symptoms of eating disorders and are recognized predictors of the
onset of the resulting clinical range of eating disorders (Stice, Davis, Miller, & Marti, 2008).
Studies about body image and unhealthy eating behaviors in Japan have been conducted
using self-administrated questionnaires to assess the prevalence of weight loss and dieting
experiences. According to the National Nutrition Survey (2004) which was undertaken in
2002 among 15-19 year olds, the rate of those who are currently trying to lose weight was
64.1% in females, which was the highest across all age groups, while the rate was 24.7% in
males. In addition, amongst the same aged female group, 68.6% and 41% of those categorized
as normal and underweight respectively were trying to lose weight (Ministry of Health
Labour and Welfare, 2004). Although the number of females who undertook a diet regime
spanned all age groups, diet behaviors by those who are underweight were significantly found
within the group of 15-19 years of age.
Unhealthy dieting behaviors appear to start in Japan in early adolescence. Some research
has shown that around 20% of 10 years old girls and boys had already undertaken dieting
experiences (Kaneko, Kiriike, Ikenaga, Miyawaki, & Yamagami, 1999; Suka et al., 2006).
The rates for adolescents who had undertaken dieting behaviors also increased as they got
older (Kaneko et al., 1999).
Some studies have investigated unhealthy eating behaviors. Mukai et al. (1994) pointed
out that 60% of female participants admitted to having at least sometimes engaged in a binge
eating and 15% of them answered that they vomit occasionally. Nakamura et al. (1999)
showed that from a sample of 406 participants, 42.4% had dieting experiences and 5.9% had
fasting experiences. In regard to the use of laxatives, diet pills and diuretics, 14.3%, 10.3%,
3.7% of them respectively have used these ways to lose weight (Nakamura et al., 1999).
The results from these studies, particularly amongst young adolescents have been and are
still inconsistent, mainly due to differences of instruments and sampling. There has been little
study on unhealthy eating behaviors among males. High rates of unhealthy eating behaviors
across the various studies indicate that there is a need to address these behaviors to prevent
the onset of widespread severe eating disorders across this group.
In summary, eating disorders, unhealthy eating behaviors and obesity can be said to be
common and increasingly prevalent health problems amongst Japanese adolescents and these
issues need to be considered as a priority for educational programs to improve body image
and related problems among Japanese adolescents.
RECENT FINDINGS FROM QUALITATIVE INTERVIEWS WITH YOUNG

JAPANESE ADOLESCENTS
The first author (NC) conducted interviews with Japanese adolescents, in line with the
assumptions drawn from the literature review regarding body image issues. These
assumptions were; 1) Japanese adolescents have similar negative body image and related
health issues as those reported in western countries, and 2) The negative body image of
Japanese adolescents is influenced by both Western culture and traditional Japanese culture.
The review shows that there is a need for qualitative studies to describe and explore the
unique Japanese body image.
Participants in the interviews were aged 13-17 years and were both male and female. A
total of 22 interviews were conducted, 11 in a public junior high school and 11 in a public
high school. All participants lived in an urban area (Osaka prefecture). Each interview lasted
for 45-60 minutes. Interview questions were asked about body image perception, influential
factors on this perception, and personal experiences related to body image, e.g. diet regimes
and exercise habits.
Body Image in Females
There were differences regarding body image perception between males and females, and
also by age. Most female participants had negative body image perceptions and body
dissatisfaction. For example, regarding body weight, even though participants were generally
in the normal weight category and knew this, some of them still said they were a little bit
fatter than that they should be. This negative body perception meant then, that they also had
high body dissatisfaction. This was then shown to be correlated with low self-esteem. To
exemplify this correlation some actually said I would be confident if I were a little bit
thinner. Although most female participants showed a degree of body dissatisfaction, there
was a difference in body image between those who were in junior high school and in those in
high school i.e. the link between negative body image and body dissatisfaction was more
evident among female participants in junior high school compared to those in high school.
High school participants tended to have the same negative body image and body
dissatisfaction as the younger participants but some had also started to accept their body as
well. The stage of pubertal growth or level of maturity as reflected by their age, seems to
account for this difference. It was confirmed that Japanese females like teenage girls in many
countries also have negative body image and body dissatisfaction.
I am fatter than other girls. I am not satisfied with my body because I want to become a
little bit thinner.
I think I am categorized in the fat group. I am not happy with this. So, I do not like my
body at all.
I think I am chubby and other girls are very thin. They eat little, but I eat a lot. I am ok
with my body as my BMI is less than 22 and I am healthy.
In terms of weight, I think I am not fat, but it would be better to be a little thinner.
It is noteworthy that when female participants talked about their body, their biggest
concern was about their legs, particularly thighs. Some talked about waist, stomach and
breasts, but most female participants referred to their legs as a trigger for negative body
image. Even if their legs were getting more muscled due to physical activity, they still
thought their legs were getting fat or thick and they wanted to lose weight to obtain thin
long legs. This is counter to western countries where athletic female legs are often regarded as
a sign of health and fitness. This situation is quite conflicting to Japanese adolescent females.
Those willing to engage in physical activity may gain some weight and become slightly
bigger due to acquired muscle. This inturn often leads them to thinking negatively about these
changes leading to dieting behaviors or to quit their activity.
My legs are very fat, especially thighs. When I sit down next to my friend, the fat on my
thighs makes me disappointed and embarrassed.
As we become senior, we roll up our skirt to make it shorter. Then we realize how nice
it would be to have thin legs. Well, I wish I could have such thin legs.
As I play basketball, my legs are getting bigger due to muscle. Even though I lose
weight, only the upper body will become slimmer and legs remain big. I do not like this.
W hen I looked at a picture with my classmates, I was so shocked that I had such fat legs.
They were fatter than that I thought. I thought, oh my god, it is too late. Then I started to think
of dieting.
I am not confident about my legs. I always try to conceal my defect by wearing a long
skirt, short pants with boots, or high heels.
I have done some physical activity since I was a little child. Its been like a habit.
Because of that, I sometimes feel unhappy that I have bigger and muscular legs compared to
other girls.
The body image of Japanese females is influenced by both westernized idea of beauty
and the traditional Japanese female ideal image. One female participant specifically
mentioned changes around the idea of beauty in regard to fashion, saying that Japanese
culture is now strongly influenced by Western culture.
I believe that traditionally people preferred more rounded to thin people and there might
have not been so many thin people. Kimono (Japanese traditional costume) suits people who
are a little bit rounded. Also, I have heard that Japanese people, particularly women, started to
become interested in being thin because the fashion industry produced clothes which suit thin
people. I thought, yeah, that's it.
Specific cultural references were not mentioned however during interviews as

participants did not explain their perceptions using evident terms such as Japanese, western,
or traditional. The reason for the desire for thinness was generally thought to be fashion and
the image of beauty in the media.
On the other hand, there is also a tendency of avoiding muscularity in females was related
to traditional image of females in Japan. There was a clear picture of traditional gender roles
in this male-dominated society in their mind. For example, when they talked about the ideal
image which males liked, they believed being smaller and slimmer than males was an
indispensable condition in order to get males attention and approval. Their body image is
strongly influenced by two cultural contexts. By aiming to adopt this complicated and
somewhat contradictory ideal, Japanese females are more likely to have negative body
perception and high body dissatisfaction.
Body Image in Males
Most of the adolescent Japanese male participants perceived their body shape accurately.
They were also basically satisfied with their body. Similar to results found in western
countries, they also tended to have a desire for increased muscularity. However, the meaning
of m uscularity was different for these Japanese adolescent males. When they talked about
muscle or muscularity, it was in the context of sports rather than physical attractiveness. In
fact, most of participants said that they only wanted to gain a little bit of muscle, but this
desire was not strong and they did not want to be bigger. Those who said that they wanted to
have more muscle wanted to have useful or practical muscle. They said they would rather
remain as they were than gain muscle to just look attractive. For them, the ideal body was
quite slim, well-toned, with slight muscularity but not too big. This image was obtained from
Japanese teen idols and models, who generally have a smaller, slim body. This aspect of the
Japanese ideal of the male body is quite unique and different from western countries where a
bigger more muscular body tends to be the ideal. Darling-Wolf (2004) also reported the idea
of this new masculinity in Japan from womens perspective by conducting interviews with
Japanese females. This is illustrated by female participants in the study who talked about men
and masculinity, specifically in the Japanese media context. The findings reported by Darling-
Wolf (2004) were consistent with the findings from males in this study. Although the reason
for the change cannot be attributed solely to the influence of the media, it is certain that the
new masculinity is more prevalent than before.
I am relatively big, but I have little muscle. I do not mind if I do not have so much
muscle as I am not fat.
I am satisfied with my body. I want to gain a little bit more muscle equally for whole
body as I want to keep my body shape itself.
I do not want to be big like a wrestler. Although I want to have muscle, my ideal body
shape is not so much muscle.
In regard to height concerns, or wanting to be taller, Japanese males were similar to

males from Western countries in that they generally wanted to be taller.
However, a clear delineation was observed and, similar to the varying degree of
muscularity desired, there was also a difference in the extent of the height desired among
Japanese male participants. This differentiation was clearly stated by some participants saying
I do not want to be too tall, either. I do not want others to think I am looking down on
them.
This theme was clearly related to and reflected traditional Japanese values around
conformity with others. Generally there was a strong desire for being similar to others.
Younger participants were more likely to have this desire to conform compared to older
participants. It is also related to the degree of their maturity. In relation to height and females,
most of the participants preferred smaller females to taller females. This was not related to the
degree of fatness of females as long as the female was healthy.
Body Image in Japanese Society
In regard to the influence of Japanese society on body image, it can be said that there is a
strong fear of negative evaluation or disapproval from others. This was most prevalent
amongst female participants. Simultaneously, they discussed receiving pressure to be thin and
discriminative ideas towards being fat and obese. These pressures have a significant influence
on how they develop their body image throughout adolescence.
I do not care if my female friends are fat or thin, but I do care how they look at me and
think of me.
Even apart from fashion, I think it is better to be thin. Good things will never happen to
me if I am fat. If I am fat, even people whom I do not know would scorn me like Hey look,
that girl is
like fat.
I am concerned about how others think of my legs. I know they would not say that my
legs are fat. I sometimes think they just do not tell me, but they actually think that way.
In addition, during this time they have to undergo stressful situations imposed by societal
expectations. For example, most participants felt stressed about study on which huge
emphasis is placed and gave specific reference to the entrance examination for high school as
being an extremely stressful period in their lives. Some high school participants gave insights
into their unhealthy life, such as lack of exercise, binge eating behaviors and weight
fluctuations.
During the entrance exam for high school, I was eating so much because of stress. At
that time, I became fairly fat although I got back to my original weight after I entered high
school. Anyway, that was very stressful. I felt a lot of pressure and that stress was turned into
eating. When I felt stressed, I ate snacks and meals too much. Then I felt sick afterwards
because of overeating.
Participants were also exposed to many factors in this thin-oriented society, which
cause negative body image such as the media, fashion, peers and school environment. The
significance of these factors varied depending on the individual.
There were however some societal factors that had a positive influence on the body
image of adolescents such as the role of the mother and the view of what is a healthy body
across the family. The mother usually looks after meals and family health in Japan. In many
instances in this study, comments from a mother prevented participants from acquiring a
negative body image and unhealthy behaviors. Also, in some cases, if the whole family had a
positive body image or was unconcerned about body shape, the adolescent tended to have a
more positive body image or at least they did not have concerns about their body.

If I went on a diet, my mother would definitely stop me. I sometimes tend to go to
extremes about things. When these urges come up, my mother always warns and stops me.
Thats why I have never been worried about dieting seriously.

I want to be a little bit thinner. But my mother has been telling me that I am not fat and I
do not need to care about body shape. So, I do not care so much.

My family does not care seriously about how we look. I believe this environment gives
me a positive image of my body. I cannot understand why other girls go on a diet.
Interestingly, few students talked about their father. When some, mostly males did, they
described them as an unsuitable and negative role model for a healthy life.
I may care about my eating habits when I become an adult. I guess work will make me
fat because of stress as my father is actually fat.
My father is trying to lose weight. His body shape is like a typical old man and that is
definitely because of lack of physical activity. Because I see him doing that, Id like to care
about my health when I become older.
My father cares about his health because he is getting metabolic syndrome. I think I
should be very careful not to become fat. I do not want to get metabolic syndrome. There is no
benefit from being a fatty.
They see their future health risks through the modeling of their father, but they tend to
have different ideas for their own life. In traditional Japanese culture, the father used to be
always respected by all family members because he works very hard for the family. As
described, the Japanese child grows up looking at the father, and previously, Japanese males
were likely to have obtained this idea of paternalism from their childhood experience.
However, the current results imply that the traditional Japanese autocratic family structure is
changing. This can go part of the way in explaining the reason why male adolescents have a
new ideal body image. Furthermore, the comments about fathers were mostly connected
with metabolic syndrome. Metabolic syndrome has recently become a widely publicized
public health concern in Japan.
I have a bad image toward fat people. I do know why, probably because of the media.
TV program tell me that fat people are unhealthy and they cant breathe well.
My body image is influenced by this society. Metabolic syndrome is one of the
influences. Actually, I have disliked being fat since I knew about metabolic syndrome.
If someone fat is on TV, the person is always treated as a metabo or fatty character.
I do not want to be like them.
The Japan Society for the Study of Obesity (JASSO) established the diagnostic criteria
for metabolic syndrome, which is assessed by the length of waist circumference and results of
a blood test. The JASSO criteria have been used as the key measurement tool in the
development of public health campaigns in Japan. This has lead to increased awareness of the
condition, but on the other hand has caused people with little true understanding of it to
stigmatize others simply based on their overweight appearance. Japanese society, including
the government, health professions and the media, currently places considerable pressure on
people to lose weight. Moreover, most participants used the term metabo which is
abbreviation for metabolic syndrome in Japanese in order to describe someone fat or obese.
They see a negative image in the term metabo although they do not know what metabolic
syndrome is about. Without a full understanding, they just receive the messages that being fat
is lazy, bad and results from lack of self-control. This perception is gained mainly from the
media. This environment appears to lead adolescents to have a fear of fat and fear of negative
evaluation from others.
CONCLUSION
The literature review undertaken for this study suggests that body image disturbance is
becoming more prevalent amongst adolescents in Japan and that the situation can be regarded
as a public health concern. Although body image issues impact on both females and males,
problems of body image are shown to most common amongst female adolescents. Some
recent studies however, also highlight a growing number of Japanese males suffering from a
negative body image and eating problems. Although, the prevalence of clinically diagnosed
eating disorders in Japan appears to remain lower than that of Western countries, subclinical
eating disorders in non-clinical settings are significant and increasing. As body image
disturbance is strongly associated with adolescent mental and physical health, many
researchers suggest that there is a need for a population-based approach to the prevention of
eating problems and the improvement of adolescent body image.
This review revealed several possible factors which are likely to adversely influence
Japanese body image. Japan continues to become a part of a globalized and Westernized
world which propagates cultural ideals of slimness, but also clings to being a non-Western
traditional society. Japanese people, particularly the younger generation, receive ideals of
beauty from both Western and Japanese traditions. Young people may undergo a great deal of
conflict between these different cultural ideals. As both sets of ideals are encouraging people
to be thin in different ways and for different reasons, the negative influence on Japanese
adolescent body image may be worse than in other countries. The Westernization,
modernization and national character of the current generation of young Japanese certainly
plays an important role in establishing their body image but the specific causal pathways
remain relatively unexplored and vague.
New findings from the research interviews add some interesting insights around the
formation of body image amongst Japanese adolescents. Female participants tend to have
negative body image and a desire for thinness related to the influence of fashion and media.
Stemming from this, they have a particular concern about the appearance of their legs. This
also appears to be linked with the traditional ideal image of the small slender Japanese
female. Males showed a relatively positive body image and a desire for muscularity. Different
from the results from studies in western countries however, their meaning of muscularity was
related to physical strength and technique for sports, and not as much related to physical
attractiveness. This new ideal image stemmed from their desire for conformity, concerns
about evaluation from others and also the influences from the media such as Japanese pop
culture.
Other causal factors as suggested in the literature review were also shown to be valid.
Among these factors, family, particularly the mother had an important role in preventing a
negative body image. In addition, Japanese adolescents have started to form different attitudes
towards family, especially the role of the father in regard to being a model for an ideal life
and good health. It should be noted that these new findings have limited generalizabilty due to
the nature of qualitative studies. However, what is clear is that body image among Japanese
adolescents includes unique aspects became of the specific cultural context. This suggests that
body image studies and educational strategies for this issue should be considered from the
Japanese cultural perspective. Health professions and educators dealing with adolescent
health should be aware of this in the development of body image and obesity prevention
education programs. In terms of cultural awareness, this qualitative study can be regarded as
the first study to contribute to exploring these new and unique aspects of body image among
Japanese adolescents.
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In: Body Image: Perceptions, Interpretations and Attitudes ISBN: 978-1-61761-992-2
Editors: Sophia B. Greene 2011 Nova Science Publishers, Inc.
Chapter 2
BODY IMAGE AMONG ABORIGINAL CHILDREN AND

ADOLESCENTS IN AUSTRALIA
Renata L. Cinelli and Jennifer A. ODea*

University of Sydney, Australia
INTRODUCTION
In the next decade, levels of obesity, body image concerns and dissatisfaction are
expected to continue to escalate in tandem for children and adolescents, including those from
diverse ethnic backgrounds (Dounchis, Hayden, & Wilfley, 2001). Holt and Ricciardelli
(2008) concur that there is increasing evidence of weight and muscle concerns that include
body dissatisfaction along with problem eating. This is an alarming trend because it has a vast
array of health implications for young people including physical, cultural, social and mental
health consequences. Young people who are overweight and obese in modern Westernized
societies are often stigmatized and ostracized, and overweight adults are known to suffer
various forms of discrimination (Strauss & Pollack, 2003; Latner & Stunkard, 2003). Body
image concerns are associated with overall poor self concept in early adolescents, including
poor physical, social and academic self concepts (ODea, 2006) as well as low overall self
esteem (Strauss & Pollack, 2003). Further to that people with poor body image are known to
be susceptible to dieting which can lead to eating disorders (Dounchis et al., 2001). The
adverse outcomes of poor body image among children and adolescents suggest an urgent need
for these issues to be addressed in both health and educational settings.
Owing to the plethora of studies surrounding adolescent and adult females body image,
it is known that dissatisfaction and a preoccupation with unrealistic thinness is entrenched
among many women (Rierdan & Koff, 1997; Snapp, 2009). This is particularly true of
Caucasian, upper class women (Rierdan & Koff, 1997; Snapp, 2009). Whilst the trends
become less prominent when focusing on males, there is recent evidence from the literature
* Author for correspondence-A/Prof Jennifer A. ODea, Faculty of Education & Social Work, Room 911, Building
A35, NSW, 2006, Australia, Tel 61-2-93516226, Fax- 61-2-93512606, j.odea@edfac.usyd.edu.au
28 Renata L. Cinelli and Jennifer A. ODea
that societal body image pressures are also reaching men (Grammas & Schwartz, 2009),
adolescents and children as young as five years old (ODea & Caputi, 2001).
Moreover, whilst there is a lack of data on minority populations, it has been shown that
the desire for the perfect Westernized body may permeate traditional cultures, such as
Pacific Islander populations (McCabe, Ricciardelli, Waqa, Goundar, & Fotu, 2009) and the
Indigenous Aboriginal population of Australia (Ricciardelli, McCabe, Ball, & Mellor, 2004;
Wang & Hoy, 2004). Further, whilst it is known that higher proportions of Indigenous
Australian adolescents are overweight than their non-Indigenous counterparts, McCabe and
colleagues (2005) recognise that little is known about the associated behaviours and attitudes
(McCabe, Ricciardelli, Mellor, & Ball, 2005). This underrepresentation needs to be addressed
in order to redress some of the health and education inequities facing the Indigenous
Australian population.
It is well known that body image perceptions are influenced by a variety of sociocultural
factors, including the media, family and peers (e.g. Hargreaves & Tiggemann, 2004; Nollen et
al., 2006; Ricciardelli et al., 2004). It has also been identified that for African Americans, the
influence on body image perceptions of parents and family is greater to that of Caucasians for
whom peer influence appears to be greater (Parnell et al., 1996). Similar to the findings of
Parnell and colleagues (1996), Cinelli and ODea (2009) found that for Indigenous Australian
adolescents, the influence of parents through advice and feedback was a prominent factor in
determining adolescents body image. This could be attributable to the strong family ties and
kinship of Aboriginal culture (Walker, 1993).
It is for the above reasons that the unique focus of this chapter will be on the body image
of Aboriginal Australians.
Body image is defined as:
A persons perceptions, thoughts and feelings about his or her own body
(Grogan, 2008, p.3).
...howpeople think, feel, and behave with regard to their own physical attributes
(Muth & Cash, 1997, p.1438).
t he multifaceted psychological experience of embodiment, especially but not

exclusively ones physical appearanceit encompasses ones body-related self-
perceptions and self-attitudes, including thoughts, beliefs, feelings and behaviours.
(Cash, 2004, p.1)
Davis and colleagues (2010) explain that body image is classically defined as the
discrepancy between ones ideal and perceived body size or ones body dissatisfaction
(Davis, Sbrocco, Odoms-Young, & Smith, 2010). Further, the authors explain that body
image is only one component of attractiveness and that, particularly cross-culturally, ideals of
attractiveness and beauty can vary and encompass many components (Davis et al., 2010).
Body image is a process that undergoes constant fluctuation throughout the lifespan and
is a composite of both psychological and physiological factors (Janelli, 1993). Janelli (1993)
further described body image as encompassing the surface and internal workings of the body
as well as attitudes, values, and reactions to ones body.
Body dissatisfaction is defined as:

Body Image Among Aboriginal Children and Adolescents in Australia 29
A persons negative thoughts and feelings about his or her own body
(Grogan, 2008, p.4).
These definitions propose that body image is a subjective concept and likely to differ
between individuals. Flynn and Fitzgibbon (1998) adopt a definition similar to Grogan (2008)
and define body image as feelings and thoughts people have about their bodies. Body image
is frequently explained as an individuals mental picture of his or her own body, as well as his
or her satisfaction with this image (Thomas, 2001). Further, body image has been postulated
as an elastic and changeable concept that can be determined through new information and
social experience (Grogan, 2008). In that way, body image can be damaged or enhanced
through outside influences, such as peers and the media. It is for this reason that school-based
education and intervention programs are of such importance in the promotion of a positive
and healthy body image.
Willows (2005) explains culture to be broadly defined as values, beliefs, attitudes and
practices that are accepted by members of a group or community. Rucker and Cash (1992)
note that body image clearly develops in a cultural context. Thus, groups from different
countries and cultures may differ in their perspectives or understandings of bodies, shapes and
weight, along with what is realistic and desirable.
Further, over the decades, there has been extensive research into the influences on body
image. Stanford and McCabe (2005) identify that society provides messages about how
people should ideally look, and that it is both the actual and the perceived messages that
influence body image. Further, these messages are not just coming from society and the
media, but from family members and peers, among other sources (e.g. McCabe &
Ricciardelli, 2003; Mellor, McCabe, Ricciardelli, & Merino, 2008; Mellor et al., 2009;
Ricciardelli et al., 2004).
It has been speculated that adoption of Western body ideals is detrimental to body ideals
of men and women due to the often unrealistic nature of these ideals (Humphry &
Ricciardelli, 2004). Mussap (2009), in a study of Muslim-Australian women, found support
for potential risks to body image encountered by women who adopt Western values, and the
benefits in retaining heritage cultural values that promote a positive self image. Similarly,
Humphry and Ricciardelli (2004) report that acculturation with Western society and the
adoption of the slim ideal female body size are the primary factors that have contributed to
higher levels of eating pathology among Asian women. Considering this, it could be
concluded that exposure to Western society and the messages it projects can be detrimental to
the health of both Western people and people from other non Western cultures.
BODY IMAGE AMONG ADOLESCENTS IN WESTERN COUNTRIES

Rosen and Gross (1987) speculate that the pressure in todays culture for women to be
thin has likely been infiltrating adolescents and has prompted many of them into weight
reducing regimes. It is well established that body image and body dissatisfaction have been
salient issues for both male and female adolescents in Western societies throughout the
1900s and into the twenty first century (Ata, Ludden, & Lally, 2007; Huenemann, Shapiro,
Hampton, & Mitchell, 1966; McCabe & Ricciardelli, 2001; Wardle & Marsland, 1990). For
example, Rosen and Gross (1987) reported that a large portion of the young girls in their
study were either currently losing or trying to lose weight and that the majority of these girls
were in the normal weight range. The findings of Rosen and Gross (1987) are both alarming
and concerning and require more recent investigation to uncover if this trend continues.
More recently, Mission Australia (2009) found that body image is a major concern for
close to a quarter of both male and female adolescent respondents. In comparing the results of
the Mission Australia reports of the past years, it can be seen that there has been a decrease in
the percentage of young people concerned about body image, from 32.3% in 2007 to 25.5%
in 2009 (Mission Australia, 2009). Whilst these findings of Mission Australia present a
positive shift, body image is still an issue of significant concern for many young people and
requires further preventative action.
In an advanced study for its time, Huenemann and colleagues (1966) found that the
teenagers were predominantly dissatisfied with their weight, fatness or leanness and stature
along with various other body dimensions. Further to that, large portions of the girls
described themselves as fat- that number growing as the age of the girls increased
(Huenemann et al., 1966). In contrast, the males thought they were too thin or were
reasonably satisfied with their body composition (Huenemann et al., 1966). Providing further
and more recent evidence of this gender difference, Storvoll and colleagues (2005) reported
that girls had a more problematic body image than boys, both in 1992 and 2002 (Storvoll,
Strandbu, & Wichstrom (2005). It seems that the early study conducted by Ruth Huenemann
and her colleagues in the 1960s had accurately identified an important trend that would
influence the self image and related eating behaviors for many decades to come.
In the half century since Huenemann et al. (1966), many authors have consistently
reported very similar findings. For instance, Wardle and Marsland (1990) also reported that
girls were likely to describe themselves as fat, and to desire smaller bodies, particularly their
stomachs, hips, thighs and bottoms. They also reported that this issue was more prominent
among older girls than among younger girls (Wardle & Marsland, 1990).
In a recent national study of body image in Australia it was found that body image issues
are not confined to girls, or to adolescents but rather, body image is a major concern among
young people regardless of gender and age, in children, adolescents and young adults
(Mission Australia, 2007). Whilst body image remains in the top three issues of concern for
young Australians, the National Survey of Young Australians 2009, reported that body image
dropped from the top issue of concern for young people, to coming third following drugs and
suicide (Mission Australia, 2009). The fact that body image is of such high concern for young
people is alarming and calls for immediate action. In support of this concern for body image,
several authors have previously reported that adolescents are dissatisfied with their bodies
(Ata et al., 2007; McCabe & Ricciardelli, 2001).
As with adults, the body concerns of adolescents are often gender specific, with
numerous studies confirming that girls feel differently about their bodies than boys (McCabe
et al., 2005; Wardle & Marsland, 1990). For instance, females are reportedly less satisfied
with their bodies (McCabe & Ricciardelli, 2001; McCabe et al., 2005; Miller & Halberstadt,
2005; Wardle & Marsland, 1990), engage in more weight loss strategies (McCabe &
Ricciardelli, 2001; McCabe et al., 2005; Rosen & Gross, 1987) and want to decrease the
overall size of their bodies/lose weight (Ata et al., 2007; Wardle & Marsland, 1990). Also,
males have a higher propensity to desire an increase in weight and muscle tone (McCabe &
Ricciardelli, 2001; Rosen & Gross, 1987), particularly their upper body (Ata et al., 2007).
This preoccupation with appearance, in particular body shape and size, and high levels of
dissatisfaction are not surprising given the socio-cultural pressure placed on young people to
attain these unrealistic ultra thin (Bowen, Tomoyasu, & Cauce, 1992; Dittmar, 2009; Jones,
2001) and ultra muscular body ideals (Jones, 2001; Labre, 2002; Pope, Olivardia, Gruber, &
Boroweicki, 1999).
Several studies have postulated that body satisfaction decreases with age for adolescent
females (Koff & Rierdan, 1991; Rierdan & Koff, 1997) and increases for males (Labre,
2002). During puberty, males and females experience various changes to their bodies and
they are more attentive to changes during this period (Ata et al., 2007), particularly changes in
weight and shape (Banitt et al., 2008). Girls experience a normative increase in body fat
(McCabe & Ricciardelli, 2001; Thomas, Ricciardelli, & Williams, 2000), which causes them
to have about twice as much body fat as boys (Rosen & Gross, 1987). This decrease in body
satisfaction in females is not surprising given that puberty moves females away from the
socio-cultural thin ideal for women (Faust, 1983; Labre, 2002; Thomas et al., 2000).
Conversely, puberty for males brings about changes, such as increases in muscularity that
inevitably brings them closer to the societal muscular ideal male body (Labre, 2002; McCabe
& Ricciardelli, 2003), which could explain the increase in body satisfaction for young males
(Labre, 2002). Also, whilst the changes associated with puberty have been linked with dieting
behaviours and body dissatisfaction for girls, pubertal development for boys may bring about
strategies to increase weight and muscle tone (McCabe & Ricciardelli, 2003).
As early as 1985, Crowther, Post, and Zaynor suggested that alarming numbers of
adolescent girls were using dangerous methods of weight control, including self-induced
vomiting (11.2%), laxative use (4.7%), and fasting (36.4%). Considering the health harming
nature of the frequent and prolonged use of these techniques, the proportion of young women
using these methods is of grave concern (Crowther et al., 1985). Williams and colleagues
(1986) reported similar findings; 8% of the subjects vomited after eating, 4% used drugs to
lose weight, and 60% regularly skipped meals (Williams, Schaefer, Shisslak, Gronwaldt, &
Comerci, 1986). Further, Williams and peers (1986) reported that whilst only 11% were
actually overweight using age specific guidelines, 36% felt they were overweight or very
overweight. This is a large and concerning discrepancy between actual weight and perceived
weight. It would be beneficial to replicate these studies to see if the proportions of adolescent
girls using these methods has grown over the past quarter century as the sociocultural thin
ideal continues to reign supreme.
The issue of body dissatisfaction in young people is widespread in Western society and
been reported in many countries including Australia (e.g. Hargreaves & Tiggemann, 2004;
Ricciardelli et al., 2004), The United States of America (USA) (e.g. Banitt et al., 2008;
Lynch, Heil, Wagner, & Havens, 2007), New Zealand (e.g. Miller & Halberstadt, 2005),
South America (e.g. Mellor et al., 2008), The United Kingdom (UK) (e.g. Wardle &
Marsland, 1990) and Norway (Strovoll et al., 2005), to cite a few.
Research shows that girls from particular ethnic minority groups may have greater body
satisfaction than their Caucasian counterparts (Flynn & Fitzgibbon, 1998). Snapp (2009)
provides the possible explanation that ethnic minority girls may not feel judged based on their
appearance, which may be related to their greater body satisfaction. In opposition to this,
several authors have recognised that belonging to an ethnic minority group may no longer
buffer the effects of negative body image in Western society due to the pervasiveness and
high saturation of these ideals (e.g. Mussap, 2009; Perez, Voelz, Pettit, & Joiner, 2002; Shaw,
Ramirez, Trost, Randall, & Stice, 2004). Similarly, in the past it was suggested that the desire
for thinness was more closely associated with females of high socioeconomic status (Rierdan
& Koff, 1997), however Rosen and Gross (1987) found that even the majority of females
from lower classes in their study were also trying to lose weight, indicating that this thin ideal
has infiltrated many divisions of society.
SOCIO-CULTURAL INFLUENCES ON ADOLESCENTS BODY IMAGE

Physical appearance and weight control are known to be major concerns for many
teenagers (Desmond, Price, Gray, & OConnell, 1986). There is agreement among researchers
that the body image of adolescents can be influenced by a number of factors including gender,
self-esteem, media messages and pressure or support from friends and family (Ata et al.,
2007; Miller & Halberstadt, 2005; Storvoll et al., 2005). Further, although adolescence is the
primary developmental period addressed in the literature surrounding childhood eating
disorders, recent research has uncovered that biological, psychological, and sociocultural risk
factors are beginning to emerge in preadolescence (Erickson & Gerstle, 2007). Similarly,
Attie and Brooks-Gunn (1989) uncovered that girls who in early adolescence felt most
negatively about their bodies were more likely than others to develop eating problems two
years later. Becker (2004) also identified that exposure to media imagery is known to have a
profound effect on adolescents and young adults. Hence preadolescence is now being
recognised as a salient and vulnerable period for the development, or prevention of body
image disturbances (Erickson & Gerstle, 2007).
McCabe and colleagues (2005) have established that whilst there is information on
females, the relationships between perceptions of media messages, body change strategies
and body image concerns for males requires more attention. The majority of the research is
focused on Caucasian populations, with less known about the body image of other racial
groups (Abrams & Stormer, 2002). Similarly, McCabe et al. (2005) reported that the
dominant literature regarding females is based around White populations, with little reference
to Indigenous populations. It is for this reason that multi ethnic studies are needed to establish
an understanding of the variance in the body image, perceptions and attitudes held by young
people, in order to best address the issue of poor body image and high dissatisfaction in
Australia, a multicultural country with such diversity.
The salience of sociocultural influences on the development of adolescents body image
is widely recognised (e.g. McCabe & Ricciardelli, 2003; Mellor et al., 2008; Mellor et al.,
2009; Ricciardelli et al., 2004; Shaw et al., 2004). McCabe and Ricciardelli (2003) recognised
that adolescence is a time of change and often messages about the body are transmitted to
young people from family and peer groups. These messages and feedback can shape body
image and influence body change strategies in both positive and negative ways, and some
messages may carry more importance depending on who it comes from (McCabe &
Ricciardelli, 2003).
Thomas (2001) further explains that womens satisfaction with body image is influenced
by a number of factors such as physical characteristics and the way others react to them,
comparison of their physique to others around them, as well as a comparison to cultural
ideals. It has been suggested that there are three main influences on attitudes and behaviour
for young people: parents, peers and the media. This has been termed the Tripartite Influence
Model (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999).
Parents have been found to be the most salient transmitters of socio-cultural messages to
adolescents of both sexes, even more important than peers and the media (McCabe &
Ricciardelli, 2003). Particularly, specific feedback from mothers and fathers was found to
affect adolescents satisfaction with their bodies as well as influencing extreme body change
strategies such as food supplementation and binge eating (McCabe & Ricciardelli, 2003).
After parents, peers have an important influence. It has been shown that the opinions of
peers are of increasing influence during preadolescence (Erickson & Gerstle, 2007). This is
also true during adolescence. McCabe and Ricciardelli (2003) researched the socio-cultural
influences on body image and change strategies among adolescent boys and girls, finding
gendered differences. For boys, feedback from best male friend influenced body change
strategies, whilst feedback from best female friend and mothers were more salient for girls
(McCabe & Ricciardelli, 2003). Mellor and colleagues (2008) interestingly reported that boys
expressed greater pressure from peers to lose weight than girls. Further, peers appeared to
wield some pressure among adolescent girls who adopt extreme weight loss behaviour
(McCabe & Ricciardelli, 2003). The influence from peers however, is not confined to losing
weight. It was found that boys reported more pressure from all sources to increase muscle
bulk than girls (Mellor et al., 2008). Surprisingly, it was reported that the pressure to gain
muscles for males was higher than the pressure for females to lose weight (Ata et al., 2007).
Often the feedback young people received regarding their bodies, in terms of weight and
shape come in the form of positive comments from parents and peers. Nowell and Ricciardelli
(2008) suggested these positive comments may serve as a double-edged sword, because
whilst they may promote a more positive body image, they could also serve as a motivator for
further self improvement.
Dittmar (2009) described the mass media as a particularly potent and pervasive source
of influence(p.2) on the development of body dissatisfaction, due to the depiction of the
ultra-thin body perfect ideal, and the use of media models who are typically underweight.
Similarly, media imagery and consumer culture has also been coined a pervasive and
powerful influence (Becker, 2004, p.535) on girls at a critical developmental stage.
Tiggemann (2002) reinforced this, explaining that the messages sent by the mass media
certainly influence societys standards of beauty. Dittmar (2009) further explained that if
women adopt the socially constructed ultra thin ideal as their own ideal self, there is likely to
be a large and psychologically significant gap between their ideal and actual self. Exposure to
these thin female images projected by the media may then highlight the gaps between the
actual and ideal self and cause negative effect and body dissatisfaction (Dittmar, 2009).
Further, the influence coming from society is not restricted to that of the media, but also
to the environment in which a person is surrounded by. Rintala and Mustajoki (1992)
identified mannequins in clothing stores as a possible influence on womens perceptions of
ideal weight. Moreover, in measuring the proportions of modern mannequins they concluded
that a woman with the shape of a mannequin would probably be too thin to menstruate
(Rintala & Mustajoki, 1992). This research shows that the unattainable extremely thin female
ideal that is promoted for women in this society is endorsed through a variety of cultural
means. Further it is damaging to mental and physical health, unrealistic and difficult to
achieve.
The above research indicates that the media is predominantly an influencing factor for
females. Conversely, McCabe and Ricciardelli (2003) found that the media did not play a
strong role in body image or body change strategies among adolescent boys. Similarly,
Mellor and colleagues (2008) indicated that boys reported lower levels of pressure from the
media to lose weight than girls.
The media, however, is not always a negative influence on body perceptions. There are
campaigns made to promote media literacy and an understanding of real beauty, such as the
Dove Campaign for Real Beauty (Dove, 2009). This campaign is uses a variety of media
avenues such as television advertising, billboards, and websites to be thought provoking and
teach people to endorse diversity, embrace all definitions of beauty, and to challenge the
narrow, unrealistic or unattainable definition of beauty portrayed in mainstream media and
society (Dove, 2009). Gaining a greater understanding of how people perceive the messages
portrayed in the media regarding body size, shape and beauty would assist in the development
of effective campaigns such as this one, and health education programs that target the
promotion of a health body image across generations.
ADOLESCENT MALES
Not only does the issue of body dissatisfaction extend to males, but recent research shows
it is an issue of significant concern for males (Mission Australia, 2009). Labre (2002)
expressed that adolescent males are increasingly experiencing body dissatisfaction, engaging
is chaotic eating and employing the use of anabolic steroids to control their weight and gain
muscle. Further, Ricciardelli and colleagues (2007) recognised the pursuit of muscularity of
many boys (Ricciardelli et al., 2007). This finding has been mirrored by many authors (e.g.
Grogan, 2008; McCabe & Ricciardelli, 2004; Nowell & Ricciardelli, 2008). Boys sighted
many reasons for this pursual, including attainment of strength, fitness, enhanced sporting
performance, physical work, dominance and health (Ricciardelli et al., 2007).
Ricciardelli and colleagues (2007) further postulated that this desire for male muscularity
is linked with Western views of the male gender role, that males should be strong, fit and
athletically successful. In the study with Fijian and Tongan boys, none of the boys mentioned
steroids or other supplements (Ricciardelli et al., 2007). This could be because they already
had naturally attained the ideal body because of their genetic predisposition to height and
muscularity or, alternatively, it may be that those supplements are not readily available in
either Fiji or Tonga.
ADOLESCENT FEMALES
Erickson and Gerstle (2007) highlighted that a prominent message being projected in
todays society to young girls is that slenderness is important and valued. Further they
recommended that high body esteem and a positive sense of ones body in terms of feelings
about weight and appearance might act as a protective factor acting to shield girls from
internalizing the thin ideal (Erickson & Gerstle, 2007).
It is reported that body image is the third major concern for adolescent females, with
27.4% of young females reporting this as a major concern (Mission Australia, 2009). It is not
uncommon for young women in Western societies to desire thinness (Banitt et al., 2008)
which is hardly surprising given the focus placed on appearance and body shape in so many
different environmental and social areas. Cohn and colleagues (1987) agreed that girls
showed a preference for thinness, and interestingly selected thinner figures as desirable than
they perceived even males would desire for females (Cohn et al., 1987).
Rierdan and Koff (1997) recognised that during early adolescence some girls may readily
accept implausible ideals surrounding thinness, or have responses from others, both from
within and outside their family about their developing bodies that leads to extreme body
dissatisfaction and a vulnerability to depression. In accordance with the normative weight
gain associated with adolescence for females (Thomas et al., 2000), BMI is significantly
associated with weight dissatisfaction and weight concerns (Rierdan & Koff, 1997).
Similarly, it is not uncommon for girls even in the healthy weight range to consider
themselves too fat (Wardle & Marsland, 1990). Desmond and colleagues (1986) had
comparable findings of girls overestimating their weight, with 39% of the thin girls
perceiving themselves to be normal weight, and 43% of the normal weight girls thinking they
are heavy.
Even positive feedback about weight and body shape can have a negative impact on the
body image of young women, as positive comments often serve to remind girls that they are
being evaluated on their looks appearance and body (Nowell & Ricciardelli, 2008).
Reinforcing this, Thomas (2001) postulated that womens satisfaction with their looks is
influenced by their physical appearance but also by the way others react to them and a
comparison of themselves to others around them. Care must therefore be taken when
educating young people, with an emphasis placed on healthy eating and exercise as opposed
to weight, shape and appearance.
YOUNG CHILDREN MALES AND FEMALES

Recent research has shown that the issue of body image and dissatisfaction is so
pervasive in todays society that it is reaching people of all ages, and both sexes, including
young children (ODea & Caputi, 2001; Saling, Ricciardelli, & McCabe, 2005; Thomas et al.,
2000).
Wardle and Marsland (1990), in an early study of adolescents, found that more than 50%
of the girls felt too fat and wanted to lose weight. Further, weight concern was almost as
high in the 11 year olds as it was in the 18 year olds, suggesting that weight concerns are
beginning earlier than previously thought (Wardle & Marsland, 1990), and reaching further
towards childhood.
Even more alarmingly, in an early study of school aged children, ODea and Caputi
(2001) found that body image and weight concerns were present in children as young as six
years old, and they noted that body image concerns increased with age. Saling, Ricciardelli,
and McCabe (2005) reinforce this notion of body image and eating issues being present in
very young children, reporting that disordered eating attitudes and behaviours were present in
young children aged 7-10 years old. Further, Smolak (2004) explained that children as young
as three years old may already be aware of anti-fat prejudice, although they are not seriously
committed to it.
Several authors have startling findings that large numbers of young people in the normal
weight range are discontent with their weight or body image and many are trying to lose
weight. Tremblay and Lariviere (2009) uncovered that in their study of young Quebecers,
around 80% of the subjects were in the normal weight range, yet, more than half of the 9-
year-olds and almost half of the 13 and 16-year-olds were not satisfied with their body image
(Tremblay & Lariviere, 2009). Similarly, Worsley and peers (1990) found that of 15 year old
New Zealand adolescents, 75% were within the normal Body mass Index (BMI) range, yet
68% of the girls and 19% of the boys wanted to lose weight (Worsley, Worsley, McConnon,
& Silva, 1990). Another was ODea & Caputi (2001) who found that about 40% of girls
considered themselves too fat, but up to 80% were actually trying to lose weight. These
findings are distressing considering such a large portion of healthy weighted children and
adolescents are discontent, and there are no health reasons for this to justify this discontent.
This clearly shows that body image, weight, shape and size are of considerable concern for
young people and that continued efforts to address the issue are critical.
Consistent with ODea and Caputi (2001), Holt and Ricciardelli (2008) highlighted that
whilst there are weight and muscle concerns present in young children, they occur with lower
frequency and intensity than they do in adolescents and young adults. Recent data from the
Mission Australia Study (2009) found that this was also the case among Indigenous youth, for
whom body image concerns increased with age.
These socio-cultural ideals of the perfect body are communicated to children very young
and through a variety of mediums. For instance, young girls aged 5-7 reported lower body
esteem and a greater desire for thinness after playing with dolls such as Barbie (Dittmar,
Halliwell, & Ive, 2006). Similarly, the male muscular ideal is portrayed to males through
action figures. Pope et al. (1999) measured the proportions of action figures and found that
over the past 30 years, the figurines have grown so much more muscular, that they now
represent muscularity that exceeds that of even the worlds most muscular body builders. It
was found that physical size was associated with success and heroism according to boys aged
12-16, who identified that less muscular actions figures looked nerdy, while more muscular
toys were more believable as superheroes (Knoesen, Vo, & Castle, 2009). Thomas and
colleagues (2000) concurred that societies pervasive ideals are advocated in young children,
even as young as seven years old.
Smolak (2004) reported that some children are already worried about their appearance in
order to be accepted by their peers. Similarly ODea and Abraham (1999a) discussed that pre-
pubescent children of both sexes who were overweight considered themselves to be less
socially acceptable. Children have been found to employ techniques such as food restrictions
and exercise in order to evoke change in their body size and shape (Smolak, 2004). It has
been stated that BMI is a major predictor of body dissatisfaction and problem eating among
children (Thomas et al., 2000). Thomas and colleagues (2000) found that children of both
sexes who had a larger BMI desired a thinner body. Further the girls with a larger BMI were
more likely to be plagued by thoughts of dieting or engaged in dieting behaviours (Thomas et
al., 2000). However, it is not just children with higher BMIs who experience body image
issues and dissatisfaction, even some children of normal weight experience problems (ODea
& Caputi, 2001).
It is unknown whether these perceptions are also held by Indigenous Australian children,
and if they are not, what their perceptions are. Further research is required in order to clarify
this.
BODY IMAGE AMONG DIFFERENT ETHNIC GROUPS

In the past, body dissatisfaction was considered to be largely restricted to Western
societies. More recent findings however, challenge this assumption (Mellor, McCabe,
Ricciardelli, & Ball, 2004) and show that body dissatisfaction is an issue reaching around the
globe to many different cultures and ethnic groups (e.g. Fleming et al., 2006; Grammas &
Schwartz, 2009; Lynch et al., 2007; Yates, Edman, & Aruguete, 2004).
A persons ethnic identity has been shown to impact body image. Ethnic identity is the
degree to which a person identifies with their own ethnic group, and influences a persons
cultural behaviours, beliefs and attitudes (Dounchis et al., 2001). A shift from identifying
with ones own culture, towards adopting the ideals and values of Western culture,
particularly in terms of body image, is known as an acculturation effect (Ball & Kenardy,
2002; Mellor et al., 2004). It has been hypothesised that ethnic identity confusion is linked
with the struggle to accept body types valued by ones own culture (Dounchis et al., 2001).
Similarly, Lynch et al. (2007) put forth that individuals who more strongly identify with
White cultural ideals of thinness may be at greater risk for eating disorders and high levels of
dissatisfaction, compared to those who more closely align themselves with more traditional
cultural ideals.
Ball and Kenardy (2002) reported that risk factors for weight and eating pathology were
present across a range of ethnic groups. Further, it was found that women who reported a
longer time since immigrating to Australia identified body weight, dissatisfaction and eating
behaviours similar to Australian-born women (Ball & Kenardy, 2002). Erickson and Gerstle
(2007) expressed that cultural messages are a salient example of a socio-cultural risk factor
for eating disturbances. These studies suggest that there may be differing perceptions of
weight issues among different cultural groups, in particular, Indigenous and non-Indigenous
young people and that the more acculturated people become, the more stereotyped, negative
and dangerously unachievable their body image may become.
This issue of belonging to two differing cultural, social worlds has been termed a culture
clash. This occurs where people who have a more traditional family background experience a
clash with the society in which they live which can lead to eating pathology (Humphry &
Ricciardelli, 2004). Culture clash is likely to occur in countries such as the USA and Australia
where there is a high degree of multiculturalism. It is for this reason that it is important to
understand what shapes the body image perceptions of the minority groups in these places.
It is well known the body image perceptions of women and men are different (Ata et al.,
2007; Fallon & Rozin, 1985; Miller et al., 2000; Muth & Cash, 1997), and that along with
gender; ethnicity and acculturation may be salient factors in the determination of body image
perceptions, body weight, and disordered eating (Ball & Kenardy, 2002). Fallon and Rozin
(1985) recognised that men think women desire heavier statured men than women actually
report, and women think men like women to be thinner than what the men actually desire.
Moreover, it was found that men do desire women to be thinner than what women perceive
themselves to be (even if their perceptions are unrealistic), which suggests there is some
realistic basis for the difference between current and ideal figures for women, and hence the
pressure women feel to pursue thinness (Fallon & Rozin, 1985).
As identified above, Western society fosters very thin ideals for women (Bowen et al.,
1992), and due to these thin body ideals many White women have high levels of body
dissatisfaction (Powell & Kahn, 1995; Yates et al., 2004) and are dieting to a degree that is
detrimental to their health (Mazur, 1986). Most women cannot achieve the levels of thinness
depicted by the media as ideal, which accounts for why such large portions of females have
poor body image and eating disorders (Grammas & Schwartz, 2009). The body ideals of
African American women however are shown to be different to those held by White women.
Research has consistently shown that White women choose significantly thinner ideal body
sizes than Black women (e.g. Flynn & Fitzgibbon, 1998; Jones, Fries, & Danish, 2007;
Powell & Kahn, 1995). This indicates that ethnicity has a salient impact on body image, as
does ones social environment.
Allan, Mayo, and Michel (1993) highlight that the social environment of most Black
women does not endorse conformity to the thin ideal, nor does it promote weight loss
activities. Similarly, Greenberg and LaPorte (1996) stated that there may be less pressure in
African American communities to lose weight. This could, in part, explain the differences in
attitudes about weight and shape found between Black and White women.
Authors have identified that most ethnicity studies on body image have focused on
differences between Black and White individuals in the USA, with less attention paid to other
minority groups (Shaw et al., 2004). However, not all Black women foster the same attitudes
regarding body preferences. There are often ambiguities in findings about the opinions and
attitudes of Black men and women. This could be in part due to overgeneralisations about a
group and neglect of important in-group differences (Flynn & Fitzgibbon, 1998).
It has previously been reported that people of Western societies have poorer body image
and a desire for lower body weight and smaller shape than other groups (Aruguete,
Nickleberry, & Yates, 2004; Jones et al., 2007; Thompson, Sargent, & Kemper, 1996).
However, contrary to this, in their multi ethnic study of Asian, Blacks, White and Hispanics,
Shaw and colleagues (2004) found that ethnic groups may have reached parity in terms of
eating disturbances owing to the pervasiveness of socio-cultural pressures to reach thinness
that is reportedly now reaching all ethnic groups. Providing further evidence of this, in their
study of African American college females, James, Phelpes, and Bross (2001) found that the
subjects had accepted the White standards of beauty as appropriate and ones that should be
achieved. This assertion has important implications for healthy body image promotion and
education interventions, and requires more research to assure this is true of all populations. It
is not known whether these findings are applicable to Indigenous Australians. Further, the
relationships between appearance norms, social status, ethnicity and health goals requires
further research (Allan et al., 1993).
African American Adolescents
As noted above, African American people and Caucasian populations often have
differing perceptions when it comes to what is attractive, healthy and desired in terms of body
shape and size. The same is true for adolescent groups of these populations. Over the past
century, there has been a plethora of studies featuring African American adolescents and their
body image perceptions (e.g. Banitt et al., 2008; Huenemann et al., 1966; Parnell et al., 1996).
Whilst concern about perceived overweight is rife among White young girls (Banitt et al.,
2008; Jones et al., 2007), early reports cited concern with underweight among Black
adolescent girls (Huenemann et al., 1966). The same difference was found among the males.
Huenemann and colleagues (1966) reported that Black girls were more satisfied with their
figures, and less concerned with wanting smaller hips and thighs then the Caucasian girls.
Similarly, and more recently, Parnell and colleagues (1996) reported that the body size
considered ideal by Black females was significantly larger than the size selected as ideal by
White adolescent females. This provides further evidence of the variance in perceptions that
exists between African American and Caucasian populations, in particular the greater
acceptance of, and often desire for larger body sizes among African Americans, even among
adolescent groups.
Canadian Aboriginals
For many Aboriginal peoples, cultural identity informs their personal attitudes, beliefs
and knowledge about food and food choice (Willows, 2005). Culture is a very central part of
Aboriginal peoples lives.
In their research with Canadian Aboriginal girls, Fleming and colleagues (2006) found
that Aboriginal culture is often strikingly different from the beliefs of people from dominant
White culture. The participants explained the difficulties faced when they cannot fit into the
dominant White culture. This culture clash was experienced by participants when their own
Aboriginal culture was in conflict with the White culture within which they live or go to
school (Fleming et al., 2006). This polarity of attitudes was particularly prominent regarding
body size perceptions, as explained by participants. For instance, on home reserves
participants explained that everybody is overweight and if you are thinner you get hassled
about being thinner, whereas away from that culture, the expectation is to be thinner (Fleming
et al., 2006).
Providing further evidence for this difference between Indigenous and mainstream
cultures were the findings of Willows (2005), regarding the cultural significance of food for
Canadian Aboriginals. The consumption of traditional foods is not just about eating; rather it
is the endpoint of a series of culturally meaningful processes including harvesting,
preparation and distribution of foods (Willows, 2005). Likewise, in many other traditional
communities food carries great significance. This is because in many cultures, such as Fiji
and some African cultures, thinness and weight loss is considered a sign of illness or
deteriorating health (Becker, 1995), or starvation (Rguibi & Belahsen, 2006) and fatness may
be considered a sign of health, beauty, prestige and prosperity (Cassell, 1995). The
significance of food and culture can impact the values and attitudes toward the body and
health.
In another study of Canadian Aboriginal girls and women, Marchessault (2004) reported
a trend for Aboriginal women to select heavier desired, most attractive and healthiest shapes
for girls compared to non-Aboriginal women. Further, the Aboriginal participants selected
heavier shapes to represent their current shape than did non-Aboriginal participants
(Marchessault, 2004). An interesting finding of this recent study was that greater proportions
of Aboriginal girls (65.8%) and women (82.5%) than non-Aboriginal girls and women
(36.1% and 62.2% respectively) expressed desires to be thinner, which suggests that
Canadian Aboriginal girls and women are very concerned about their weight (Marchessault,
2004). These findings are a little ambiguous and contradictory and call for further
clarification. Nonetheless, this highlights that weight concerns are rife among even minority
populations.
The unexpected findings of Marchessault (2004) which shows greater proportions of
Aboriginal girls desiring to be thinner, provides evidence that not all Aboriginal populations
are the same and means care must be taken when generalising results with specific
populations. Willows (2005) identified that the varying preferences for body size found
among Aboriginal peoples may be based in traditional cultural values. Further, it was
postulated that culture changes in response to social dynamics that change over time, and
influence from non Aboriginal cultures cannot be ignored in terms of adoption of body size
preferences (Willows, 2005).
Native Americans
Unlike the abundance of research surrounding the African American population, there are
fewer findings with specific reference to Native Americans in terms of their body image
perceptions and behaviours. There are many similarities between the two populations, such as
a higher BMI than Caucasian populations (Lynch et al., 2007) along with several most
important differences.
A prominent article by Lynch and colleagues (2007) explores the ethnic differences,
weight concerns and eating behaviours of Native American, White and Hispanic adolescents
(Lynch et al., 2007). The Native Americans had higher BMIs, on average than the Hispanics
and Caucasians in the study. Unlike African Americans who have also been found to have
higher BMIs than other groups as well as a greater acceptance of larger body sizes (Flynn &
Fitzgibbon, 1998; Powell & Kahn, 1995), the Native American adolescents were discussed as
engaging in high rates of purging behaviours and problematic eating (Lynch et al., 2007).
Further to that, it was found that for Native American boys there is a significant link between
BMI and purging behaviour, which indicates that purging behaviour may be a particularly
significant problem for these Native adolescents, particularly the overweight boys (Lynch et
al., 2007).
Acculturation levels have been identified as a determining factor in the etiology of eating
pathology. Several authors have identified that the degree of acculturation may be a key
factor influencing body image (Cachelin, Monreal, & Juarez, 2006). Similarly, Perez and
colleagues (2002) found that the relationship between body dissatisfaction and bulimia was
intensified among ethnic minority women who reported high levels of acculturative stress. It
was further explained that combining acculturative stress and body dissatisfaction may cause
minority women to experience a greater vulnerability to bulimic symptoms, whereas the
nonexistence of acculturative stress in minority women may serve as protective from bulimic
symptoms, even with the presence of body dissatisfaction (Perez et al., 2002).
BODY IMAGE RESEARCH FROM NON WESTERN COUNTRIES

INCLUDING THE SOUTH PACIFIC AND AFRICA
Around the world, perceptions of the ideal body can be very different, and in fact, even
completely opposite. As previously mentioned, in Western countries such as the USA
Australia and New Zealand, the focus is on extreme thinness and low levels of body fat
(Mazur, 1986; Miller & Halberstadt, 2005), which is vastly different to the traditional
attitudes found in countries such as Fiji, Pacific Islands, Indonesia, and Tonga where there is
often an acceptance of, or desire for, larger body sizes, including a pursual of muscularity
(McCabe et al., 2009; Ricciardelli et al., 2007; Williams et al., 2006).
The focus on muscularity found in Western society for males, appears to be present also
in non-Western societies (Ricciardelli et al., 2007). Similarly, in contrast to traditional
preferences that favoured large, robust bodies, research has documented a shift towards
thinner ideal body shapes among Pacific Island populations (McCabe et al., 2009). The
Western body ideals have become increasingly pervasive in recent years. Internalization of
the Western thin ideal has been proposed to explain the increase in body dissatisfaction and
eating disorders even in non-Western women (Mussap, 2009). There is a growing body of
evidence that demonstrates a shift towards thinner ideal body shapes among Pacific Island
and non-Western populations in contrast to traditional robust bodies (McCabe et al., 2009).
This comes with the rapid globalisation and spread of media influences, such as the
introduction of television (Becker, 2004). Becker (2004), in congruence with Mussap (2009),
recognised that eating disorders, that were once prevalent in post-industrialised and Western
societies, now have a global distribution.
In Beckers (2004) study of Fijian adolescent girls, the influence of television on body
image was striking. When asked whether television has affected the way she feels about her
weight and body, one participant articulated that very muchwhen I see them (television
actors) I think that I have to lose weight (Becker, 2004, p.541). Another participant
recognised the affect television has on Fijian culture: Culture in Fiji normally accepts
women here as big, heavy. In the TV, women are thin, so it has affected cultural traditions in
Fiji (Becker, 2004, p.542). These examples show that with the introduction of television and
the media, traditional cultures, views and attitudes are changing, to be more aligned with
Western views. This provides further evidence for the notion that this thin ideal is so
pervasive it is invading many cultures globally.
In traditional communities, it has often been reported that muscularity is desired for
attainment of strength and fitness, sporting performance, physical work, dominance and
health (Ricciardelli et al., 2007). McCabe and colleagues (2009) also cited that males chose
functional reasons for muscularity. Despite the reported increase in the adoption of the
Western thin ideal, in their study of Fijian and Australian adolescent girls, Williams and
colleagues (2006) found that the Fijian girls did not desire extreme thinness, and they were
more focused on their functionality of their bodies, compared with the Australian girls who
desired thinness to look aesthetically pleasing. Further to that, Fijian girls had no concept of
their weight (in kilos) or size (in clothes) (Williams et al., 2006). These measures were
irrelevant to them, which indicates that care must be taken when conducting research with
minority, or traditional groups, to ensure relevance and understanding.
It is known that there is a high prevalence of obesity and diabetes in people from non-
Western countries or traditional cultures such as Fiji and Tonga (Mavoa & McCabe, 2008),
This higher prevalence of disease is often attributed to the Thrifty Gene (Neel, 1999). The
thrifty genes are said to aid an individual to collect and process food to store fats during times
of food abundance, in order to aid survival during times of food scarcity (Neel, 1999). It has
been suggested that since in Western modern society, there is always an abundance of food,
hence the higher obesity rate. Neel (1999) postulated that the changing dietary patterns of
Western civilisation has compromised a complex homeostatic mechanism. This thrifty gene
hypothesis has been applied to traditionally hunter-gatherer populations. It is not known
whether it is applicable to Indigenous Australian populations, however could be a possible
explanation for the higher rates of obesity and diabetes facing this population. This could
possibly also explain the higher tolerance, and prevalence of overweight and obesity among
some groups, such as Moroccan Sahraoui woman (Rguibi & Belahsen, 2006), Fijians
(Williams et al., 2006) and Black populations such as African Americans (Alleyne & LaPoint,
2004).
Yates and colleagues (2004) reported that Pacific Islander women tend to be heavier than
many others, yet more accepting of their bodies despite their size. This is consistent with
reports from other non-Western countries where by women are more accepting of larger
bodies sizes, such as Fijians and Tongans (Mavoa & McCabe, 2008).
It is well established that men, across most cultures, have a more positive body image
than women (Bowen et al., 1992; Davidson & McCabe, 2006). This however, does not mean
that men are satisfied with their body weight and shape. The body of research that examines
the body image of men across cultures has uncovered inconsistent findings (Ricciardelli,
McCabe, Williams, & Thompson, 2007.
Cultural differences are common, with White males presenting with the lowest levels of
body/self dissatisfaction compared with over one third of Hawaiian males, who were already
quite large, desiring a larger stature (Yates et al., 2004). Similarly, nearly 40% of Japanese
males wished to be larger (Yates et al., 2004). Grammas and Schwartz (2009) also found that
Asian males were less satisfied with their amount of muscularity than Caucasian males. This
shows that body dissatisfaction is a salient issue for both men and women all across the globe,
and not just specifically in regard to Western populations. This issue requires further and
more extensive research in non-Western countries due to the lack of knowledge regarding
perceptions and attitudes coupled with the high rates of obesity, diabetes and other illnesses.
Body image and dissatisfaction is not an issue confined to adult. In a salient study, it was
found that, when examining ideal body sizes chosen by Chinese children, the gender
difference was clear in children as young as six years old, in that boys chose significantly
larger sizes for themselves than did the girls (Li, Hu, Ma, Wu, & Ma, 2005). These
perceptions which differed by gender were further reinforced as girls chose smaller ideal
body sizes for the boys than the boys chose for themselves, and the boys chose larger ideal
body sizes than the girls chose for themselves (Li et al., 2005).
Li and colleagues (2005) also found that children and adolescents ideal figure selection
was similar and had no relation to their own BMI status. Further to this it was found that the
mental representation children under 5 had of their own body was not necessarily an accurate
representation of their body (Li et al., 2005). The majority of children reported satisfaction
(40.1%) with their bodies, with less mildly dissatisfied (36.4%) and about one fifth
moderately dissatisfied (23.5%). However, Chinese children and adolescents did not show
greater body dissatisfaction compared to their counterparts in developed countries (Li et al.,
2005). Interestingly, in contrast with children in developed countries, more Chinese girls
desired a larger body (Li et al., 2005).
BODY IMAGE RESEARCH IN AUSTRALIA

Compared to the USA, there is little research that has been conducted in Australia with
specific reference to body image perceptions and attitudes. That said, there have been authors
who have contributed significantly to the body of knowledge. It is reported that body image in
Australia is similar to that of other Western countries, whereby females are greatly
preoccupied with thinness and desire to be smaller (Monteath & McCabe, 1997), while men
desire lean muscularity (Stanford & McCabe, 2005). According to Yager and ODea (2005),
body image and weight control issues affect the majority of young adults in some way and to
some degree. Due to the pervasive and widespread nature of body dissatisfaction in modern
day society, it is essential that educational efforts are made to tackle these unrealistic ideals.
BODY IMAGE IN AUSTRALIAN ADOLESCENTS

Adolescence, and puberty, is a challenging time for young people, particularly young
women, whom are at risk for low self-esteem and dissatisfaction with body shape and weight
(ODea & Abraham, 1999b). ODea and Abraham (1999b) highlighted that puberty is often a
more positive experience for young males, as the weight and shape changes they endure are
often desired, with most males desiring to build up their bodies. Further, due to the personal
nature of body image, there is frequently an ambiguity surrounding the issue and various
peoples personal attitudes that pose as a barrier to addressing the issue in a way that is
relevant and appropriate for everyone.
The literature on the impact of ethnicity or culture on the body image of young people is
not concrete in whether such impact is positive or negative, or whether there may be some
protective factor from unfavourable body image provided by ethnicity (Cinelli & ODea,
2009). Also ODea (2002) discovered that body image education programs have the potential
to have negative consequences, reporting that some types of body image education may be
unsuitable and potentially dangerous for adolescent females. The prevention of body image
and eating problems using educational strategies is among the most prominent goals in
contemporary adolescent health education (ODea, 2002). The ambiguity of findings of the
impact of ethnicity and education programs screams for further research into programs and
campaigns that are relevant and appropriate for their target groups, such as Indigenous young
people and minority migrants.
In the recent Mission Australia report, body image was of greater concern for Indigenous
young people (34.9%) than it was for the non-Indigenous respondents (32%) (Mission
Australia, 2007). On the contrary, in a study of 19 rural and 28 urban Indigenous adolescents,
Mellor et al. (2004) found that Indigenous adolescents placed less consequence on body size
and shape, with the girls in particular reporting less dissatisfaction with their body shape, and
weight compared to non-Indigenous adolescents. This disparity indicates the need for further
clarification into the issue.
In a recent study of Indigenous Australian and Anglo-European adolescents, Cinelli and
ODea (2009) found that the desire for weight loss was lower among Indigenous girls
compared with their non-Indigenous peers. Interestingly, it was found that the desired body
ideal of both male and female Indigenous adolescents was to be bigger and more built up
than their current weight (Cinelli & ODea, 2009). This finding suggests that todays
generation of Indigenous young people may be more likely than others to accept and desire a
certain bigness, muscularity or fatness (Cinelli & ODea, 2009).
In their study of Australian adolescent males, Stanford and McCabe (2005) explained that
males desire a lean and muscular body and hence desire fat loss and an increase in muscle
mass. This is similar to the findings of other authors (e.g. McCabe, Ricciardelli, & Ridge,
2006; ODea, 2008). ODea (2004; 2005b) expressed that young male adolescents are known
to be concerned with their body size and shape and to partake in weight control and weight
gain behaviours that may be detrimental to their health. Interestingly, in their study of 397
adolescent males weight gain practises and reasons for desired weight gain, ODea and
Rawstorne (2001) found that one third of males were actively trying to gain weight. Similarly
Paxton and colleagues (1991) found that males around half of the males in their study thought
that losing weight would be detrimental and that bigness is a positive feature in males (Paxton
et al., 1991). The reasons cited by the boys for weight gain were to be stronger, fitter, to have
a better body image and to do better at sports (ODea & Rawstorne, 2001). ODea and
Abraham (1999b) also found that pubertal males desired to build up their bodies, believing
that appearance was important to their sexual appeal. Whilst it is not explicit, these reasons
indicate that the desire for weight gain may be for increased muscle, as in other studies
(ODea, 2008) and not necessarily fat gain (Paxton et al., 1991).
In terms of influences on adolescent male body image, Stanford and McCabe (2005)
found messages regarding body size and shape were important. However, it was not the
intention of the message provider that was of importance, rather the interpretation of the
messages that influenced attitudes and behaviour. These messages were conveyed through
role modelling, direct communication, teasing or otherwise (Stanford & McCabe, 2005).
Adolescent girls are also affected by the messages transmitted to them (Hargreaves &
Tiggemann, 2004).
Not only are there gender differences between adolescent males and females, but there
are distinct differences between females of different cultures. In a study of Fijian and
Australian adolescent girls, Williams and colleagues (2006) found that for Australian girls a
focus on weight and size was a salient theme for their descriptions of their own bodies, whilst
Fijian girls had not concept of their own weight or size in kilograms and were more likely to
describe themselves in terms of functionality.
ODea & Abraham (1999a, 2001) found that postmenarchial adolescent females had
poorer body image and poorer perceptions of their physical appearance than premenarchial
peers and postulated that this is associated with the rapid increase in height, weight, and body
fat that precedes menarche. Further to that, it was found that postmenarchial females were
more likely to clearly articulate the meaning of dieting, to report trying to lose weight and to
use diet and exercise to lose weight (Abraham & ODea, 2001). Further, after menarche
females has increased personal expectations and were dissatisfied with their weight and shape
changes (ODea & Abraham, 1999b). This indicates that education efforts must be targeted at
young women prior to the weight gain associated with menarche, in order to equip females to
adequately deal with, and accept their changing bodies in positive and healthy ways.
Food and attitudes surrounding food are an important consideration when examining
body image and body satisfaction. There is a high degree of variance of attitudes towards
food and significance of food from culture to culture, which could in part explain why body
image is different across cultures. In 1999(a), ODea found that among children and
adolescents, food concerns increased with age for girls, and decreased with age among boys.
Further in that study, nearly a third of participants identified concerns about food, and
interestingly, the type of concern did not vary according to age or socioeconomic status
(ODea, 1999). The majority of participants citing concerns were older girls who were
focused on weight control (ODea, 1999). This is not surprising considering it has been
shown that older adolescent females often desire weight loss following the weight gain
associated with puberty (Abraham & ODea, 2001).
In another study, ODea (2003b) found that adolescents identified motivators for
healthful eating included feeling cleansed, refreshed and energised and that young people
were looking to their parents and teachers to encourage, support and enable them to be
involved in healthful eating behaviours (ODea, 2003b).
It has been identified above that a frequent opinion of adolescent females is that they are
too fat. ODea and Caputi (2001) came across the interesting discovery that approximately
40% of the girls perceived themselves as too fat, yet up to 80% were trying to lose weight.
This could indicate that there are reasons other than perceived excess weight for pursuing
weight loss.
ODea (2004) illuminated that body image concerns, chaotic weight loss behaviours, and
eating problems pose a grave risk to the short and long term physical, psychological and
social health of young people and intervention programs and more important now than ever.
BODY IMAGE RESEARCH AMONG CHILDREN

In a large, recent nationally representative study of 7889 schoolchildren in Australia,
ODea (2008) found trends suggesting that obesity is more common among low
socioeconomic status (SES) students and those from Middle Eastern or Pacific Islander
backgrounds. Further, ODea (2008) reported that the prevalence of obesity among these
groups was around 20%. This is alarming when compared to the Anglo/Caucasian children
the same age, for whom the prevalence of obesity was 5-7%. This data is suggestive of
significant cultural or ethnic differences between groups, and indicates a need for concern
over the possible future development of type 2 diabetes for these groups.
ODeas (2008) national study also uncovered an absence of concern coupled with
significant level of body satisfaction from obese children of Middle Eastern and Pacific
Islander backgrounds. This finding is further supported by McCabe and colleagues (2009)
who reported that overweight Fijians and Tongans were more satisfied with their body than
Indo-Fijian or Australian adolescents. This indicates that some cultures support attitudes that
are more accepting of larger body sizes. Some cultures view fatness as a sign of prosperity,
fertility and success (ODea, 2008).
In another study, ODea and Caputi (2001) found that children of low socioeconomic
status were more likely to be overweight, to skip breakfast, to perceive themselves as too
thin, to be trying to gain weight, and less likely to receive dietary or weight control advice.
This is concerning as the perceptions of being too thin and efforts to gain weight may
contribute to the increasing prevalence of child overweight and obesity. Further, this is
concerning for Indigenous children who also fall into the low socioeconomic group, as this
overweight and lack of dietary advice may perpetuate the cycle of poor health and
disadvantage.
Overweight, perceived overweight and weight concerns are known to precede dieting,
hazardous weight loss and eating disturbance (ODea, 2005b). Because of this there is a trend
toward the co-occurrence of increasing eating disorders and increasing child overweight that
is of grave concern, and these two trends can be expected to continue in tandem (ODea,
2004, 2005b). The challenge facing health and education professionals is to teach young
people about healthy lifestyle and food choices without causing more body image concerns.
As with adolescents and adults, there are gender differences present with children in
terms of their body attitudes and image. ODea and Caputi (2001) found that overweight
females were more likely to consider themselves too fat than overweight males, and
overweight males were more likely to consider their weight to be about right than
overweight females. This could be due to the stereotypes of modern day society prescribing
that females be thin and males be bigger (more muscular). Further, approximately half of the
overweight 6-12 year old children considered their weight to be about right and about a
third of the 12-19 year olds thought the same (ODea & Caputi, 2001). This indicates that as
these children get older they may become more aware of the thin ideal. The authors suggested
that its possible that these children are somewhat protected by not having received any
weight control advice and are therefore less exposed to the doctrine of thinness that promotes
dissatisfaction (ODea & Caputi, 2001).
A particularly salient finding is that body image and weight concerns were present in
children as young as six years old and that the concerns were increasing with each age group,
particularly females (ODea & Caputi, 2001).
A summary of Australian body image research related to children and adolescents is
presented in Table 1 below.
Table 1. Body image research conducted among Australian children and adolescents.

Rolland, Farnill, & 139 (females) 8-12 39% of girls and 26% of boys wanted to be thinner than they perceived
Griffiths (1996) 105 (males) themselves to be.
In the overweight quartile, 76% of girls and 56% of boys wanted to be
thinner, whereas in the underweight quartile only 10% of girls and no
boys wanted to be thinner.
Rolland, Farnill, & 139 (females) 8-12 50% of girls and 33% of boys have wanted to be thinner, and 40% and
Griffiths (1997) 105 (males) 24%, respectively, have attempted to lose weight.
Percentages of girls and boys scoring above the ChEAT screening
threshold for anorexia risk were 14% and 8%, respectively.
Sands, Tricker, 26 (females) 10-12 Females were more inclined to involved themselves with weight loss
Sherman, Armatas, 35 (males) practices than males.
& Maschette (1997) Found: Body image views and concerns appeared before puberty and
that gender differences prevailed with respect to eating/dieting, activity
and body image.
Table 1. (continued)

ODea (1999) 468 (both) Primary Food concerns increased with age among girls and decreased with age
school among boys. Children in this study indentified concerns about food. The
children type of concern did not vary among age or SES group.
Self concept was a predictor of problem eating for both genders.
Thomas, 97 (females) 8.22 (mean BMI was a predictor of body dissatisfaction for both genders.
Ricciardelli & 105 (males) from grade 3) With the onset of puberty, girls experience a normative increase in body
Williams (2000) 9.27 (mean fat which inevitable moves them further away from societies ideal body
from grade 4) shape for women.
Magarey, Daniels, 1985 sample: 1985 sample: Levels of overweight and obesity for both boys and girls increased from
& Boulton (2001) 8492 7-15 1985 to 1995. Depending on age, 13-26% and 19-23% of Australian
1995 sample: 1995 sample: boys and girls, respectively, aged 2-18 years are overweight of obese,
2962 2-18 with prevalence peaking at 12-15 years in boys and 7-11 years in girls.
ODea & Caputi 225 (females) 6-12 Low SES children were more likely to be overweight, to skip breakfast,
(2001) 241 (males) to consider themselves too thin, to be trying to gain weight and less
likely to receive dietary or weight control advice.
Body image and weight concerns were present in children as young as 6
years old. 14% of normal weight females thought they were too fat,
compared with 5% of normal weight males.
A larger portion of normal weight females (28%) were trying to lose
weight than normal weight males (16%) whilst more normal weight
males were trying to gain weight (16%) compared to 4% of females.
50% of the overweight girls and 70% of the overweight boys perceived
themselves to be about right. More of the overweight girls (47%) than
boys (25%) thought they were too fat.
Williamson & Delin 94 (males) 5-10 Girls, irrespective of age, preferred smaller ideal than current shapes and
(2001) 101 (females) expressed greater body dissatisfaction than did the boys.
Emergence of thin ideal in girls as young as 5 years old.
ODea (2003a) 4441 6-13 BMI was significantly higher among low-SES than middle/high-SES
participants.
Low SES primary school children were 1-2cm shorter, on average, than
middle/high SES primary school children.
SES is a factor in the development of overweight and obesity in
Australian school children.
ODea (2004) review Children and Development of a positive self image and a strong sense of self worth is
Adolescents likely to help children and adolescents become more satisfied with their
body shape and size and more resilient and resistant to the unrealistic
body image ideals portrayed in the media.
Wang, Byrne, 768 10-18 Females and older children were more likely to desire thinner figures
Kenardy, & Hills than their perceived current figures.
(2005) 28.3% of 10-14 year olds experienced body dissatisfaction.
Age and gender differences in body image and eating problems were
present in children and adolescents.
Marsh, Hau, Sung, 763 8-15 Results suggest stronger Chinese cultural values of moderation and
& Yu (2007) acceptance of obesity than in Western culture.
*Chinese children
compared with
Western children.
ODea (2007) 1243 (males) Primary 6.4% of males and 5.6% of females were obese.
1347 (females) school 6.2% of males and 6.8% of females consumed a nutritionally adequate
children breakfast.
Gibbs, OConnor, 23 schools 5-12 Body image concerns in children as young as 5 years old.
Waters, Booth, Recognises body image as integral part of obesity prevention.
Walsh, Green,
Bartlett, &
Swinburn (2008)
O'Dea (2008) 7889 6-11 Obesity more common among low SES students & those from Middle
Eastern & Pacific Islander backgrounds.
The prevalence of obesity was about 20%, surprising, considering
comparative prevalence among the same aged children from
Anglo/Caucasian backgrounds was 5-7%.
ABORIGINAL AUSTRALIANS
A summary of studies that include the body image of Aboriginal Australian adolescents
is given below (Table 2)
Table 2. A summary of body image research conducted among Aboriginal Australian

adolescents.
Mellor, 47 12-16 Males place more consequence on muscle size and

McCabe, strength than girls.
Ricciardelli, & Overall Indigenous adolescence of both sexes place less
Ball (2004) importance on their body shape than non Indigenous
adolescence and less appear to be dissatisfied with their
weight.
Indigenous girls in particular appear to be less dissatisfied
with their weight.
Ricciardelli, 22 (males) 25 12-16 Sociocultural influences were found to be associated with
McCabe, Ball, (females) body image concerns and body change strategies among
& Mellor both Indigenous and non Indigenous cultural groups.
(2004) Indigenous girls and non Indigenous boys were similar in
terms of their lack of concerns.
McCabe, 50 (males, 25 12-16 Girls were more likely to be dissatisfied with their weight
Ricciardelli, Indigenous, 25 and engage in strategies to lose weight.
Mellor, & Ball non Indigenous adolescents engaged in more strategies to lose
(2005) Indigenous) 50 weight, increase weight, and increase muscles than non
(female, 25 Indigenous adolescents, despite perceiving fewer messages
Indigenous, 25 about losing weight.
non
Indigenous)
ODea (2008) 7889 12-18 Obesity more common among low SES students & those
from Middle Eastern & Pacific Islander backgrounds.
The prevalence of obesity was about 20%, surprising,
considering comparative prevalence among the same aged
children from Anglo/Caucasian backgrounds was 5-7%.
Obese Aboriginal, Pacific Islander & Southern European
girls seeing their weight as acceptable & possibly even
desirable.
Cinelli & 4367 12-16 Indigenous adolescents, male and female, were more
O'Dea (2009) likely than their non Indigenous peers to desire and pursue
weight gain.
Indigenous adolescents were more likely to receive
parental and familial advice about the desirability of
weight gain.
BODY IMAGE RESEARCH RELATED TO ABORIGINAL

AUSTRALIAN ADOLESCENTS
With few exceptions (e.g. Cinelli & ODea, 2009; McCabe et al., 2005; ODea, 2008;
Ricciardelli et al., 2004; Turner & Graham, 2005), there are almost no data available
specifically on the body image and attitudes of Aboriginal Australians.
Whilst it is known that higher proportions of Aboriginal Australian adolescents are
overweight than their non-Aboriginal counterparts, McCabe et al. (2005) recognise that little
is known about the associated behaviours and attitudes. In a study conducted with 333
Aboriginal Australians, it was found that the majority of them perceived themselves to be
just right (71%), while 10% felt they were too skinny and 19% believed they were too
fat (Turner & Graham, 2005, p.3). It is reported that the responses given were often different
to the observed body weight of the participant (Turner & Graham, 2005) indicating that for
Aboriginal Australian people weight may have different meaning than for non-Aboriginal
people. This idea that Aboriginal people may have different meanings attached to weight than
other Australians is similar to the findings of Williams and colleagues (2006) that Indigenous
Fijian girls had different concepts and perceptions of their weight and size than Australian
girls.
Similarly, according to Cunningham and Mackerras (1994) 61% of the Aboriginal males
and 57% of the Aboriginal females were categorised as being overweight or obese. This is
interesting considering 71% of the participants in Turner and Grahams (2005) study
considered themselves to be just right. ODea (2008) provided further evidence of this
reporting that obese female adolescents from Aboriginal, Middle Eastern/Arabic and Pacific
Islander backgrounds were less likely than their Caucasian or Asian peers to consider
themselves too fat. Not only did one third of these obese girls see their weight as acceptable,
but possibly even desirable. This is in stark contrast with their Anglo/Caucasian and Asian
peers, whom nearly 100% perceived themselves to be too fat (ODea, 2008). These studies
indicate that a tolerance of overweight and obesity may be present among Aboriginal people,
similar to that of African Americans (e.g. Parnell et al., 1996). It is for this reason that it is
necessary to gain a comprehensive understanding of how Aboriginal Australians perceive
body weight, underweight, overweight and obesity, in order to assist health and education
professionals to best approach these issues among this specific population group.
SUMMARY
This chapter details body dissatisfaction as a global phenomenon that effects many men,
women and children around the world, who are concerned with bettering themselves by
pursuing the ideal body which may be ultra-thin or ultra-muscular, and often, ultra-
unhealthy. The impact this issue has on young people around the world is clearly one of
importance, and considering the vast health inequalities facing our very own Australian
Aboriginal population, in the way of disproportionately high rates of obesity, diabetes, and
other health problems, it is an issue that desperately needs to be addressed. There is a distinct
lack of research focusing on Aboriginal Australians, and the ones that exist, have mixed
findings or require further clarification. It is fairly consistently reported however, that
Indigenous adolescents are less concerned with their weight than their non-Indigenous peers
(Cinelli & ODea, 2009; Mellor et al., 2004; ODea, 2008; Ricciardelli et al., 2004).
Considering the vast differences that occur between Aboriginal groups, it is important to take
care when generalizing findings.
Owing to this large gap in the literature, and in the health status and education of
Aboriginal Australians, it is imperative that programs and initiatives be developed to deliver
culturally appropriate and sensitive health education aimed at closing the gap, and ensure that
body image issues are addressed in a way that does not create concern when it does not
already exist.
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Chapter 3
THE PSYCHOLOGY OF BODY IMAGE:

UNDERSTANDING BODY IMAGE INSTABILITY
AND DISTORTION
Jennifer S. Mills, Kaley Roosen and Rachel Vella-Zarb

Department of Psychology, York University, Toronto, Canada
ABSTRACT
In this chapter we consider the psychology of body image and analyze the concepts
of body image instability and body image distortion. Rather than representing a stable or
static trait, we propose that body image is in constant flux, continuously shifting as a
result of factors both internal and external to the individual. We review the literature
supporting the view that peoples perceptions of the size and/or shape of their bodies are
not fixed. Drawing from published empirical studies, including research on personality,
the effects of exposure to media images, social norms, and weight-related feedback,
determinants of body image will be reviewed and critically examined. As a corollary to
the concept of body image malleability, it is further proposed that people tend to be
inaccurate when assessing what their bodies look like. Much of the research to-date on
body image distortion has focused on individuals with clinical eating disorders who
exhibit extreme body image distortion (e.g., anorexia nervosa). Such individuals typically
believe that their bodies are much heavier than they really are. However, even individuals
without clinically significant disorders are often poor at recognizing the size and shape of
their own bodies. Interestingly, people tend to underestimate their weight (in lb or kg),
whereas they tend to overestimate their body size. Possible reasons for this discrepancy in
body image accuracy findings are discussed. In summary, people generally exhibit what
we call poor body acuity. There is little evidence of perceptual dysfunction underlying
body image inaccuracy and distortion. However, certain perceptual influences (i.e.,
attentional biases) appear to exacerbate poor body acuity.
60 Jennifer S. Mills, Kaley Roosen and Rachel Vella-Zarb
INTRODUCTION
Two of the most interesting themes in body image research are the stability and the
accuracy of peoples body image. Much of the published research conducted on body image
in the past few decades has been related to body image disturbances that accompany clinical
eating disorders, including anorexia nervosa and bulimia nervosa. These conditions affect
mostly women, occurring at a female: male ratio of 10:1 (APA, 1994). Anorexia nervosa, in
particular, involves gross misperceptions of the persons own body, typically resulting in the
individual perceiving herself as much heavier or fatter than she really is (APA, 1994).
Although disturbances in body image that accompany the eating disorders can be extreme in
terms of both their extent and their resistance to treatment, even many non-eating disordered
individuals experience instability and distortions in their body image on a regular basis. One
might assume that people would have a relatively stable sense of what their bodies look like.
Instead, it appears that body image changes frequently and as a result of many influences.
Similarly, one might assume that people would be accurate at perceiving the size and shape of
their own bodies. On the contrary, research has shown repeatedly that people are generally
inaccurate at estimating what their bodies look like. These phenomena are important to study
not only for theoretical reasons (i.e., to understand the determinants of body image), but also
because peoples perceptions and evaluations of their bodies can lead to distress and
impairment.
In this chapter we consider the psychology of body image and analyze the concepts of
body image instability and body image distortion. Rather than representing a stable or static
trait, we propose that body image is in constant flux, continuously shifting as a result of
factors both internal and external to the individual. We review the scientific literature
pertaining to research on the stability of peoples perceptions of the size and/or shape of their
body. Drawing from published empirical studies, including research on personality, the
effects of exposure to media images, social norms, and weight-related feedback, the major
determinants of body image are reviewed and critically examined. Furthermore, we propose
that people are generally inaccurate when assessing what their bodies look like. Most of the
research to-date on body image distortion has focused on individuals with clinical eating
disorders, such as anorexia nervosa. However, we argue that even individuals without
clinically significant disorders are generally poor at recognizing the size and shape of their
own bodies. Interestingly, people without clinical eating disorders tend to underestimate their
weight and overestimate their body size. We review the research literature on body image
accuracy and discuss some possible explanations for body image inaccuracy, including
perceptual aspects of body image. Finally, suggestions for future research on body image
instability and inaccuracy are presented.
THE MEANING AND MEASUREMENT OF BODY IMAGE

The term body image was originally defined in the first half of the 20th century by
Schilder as th
e picture of our own body which we form in our mind, that is to say, the way in
which the body appears to ourselves (Schilder, 1950, p.11). A more recent definition by
Slade (1988) of body image is the picture we have in our minds of the size, shape, and form
The Psychology of Body Image 61
of our bodies; and to our feelings concerning these characteristics and our constituent body
parts (p. 20). This more recent definition reflects the growing recognition in the latter part of
the 20th century that body image is both perceptual and evaluative (see also Rudd & Lennon,
2000). Today, body image is a psychological construct that has proven useful for explaining a
range of health-related behaviours, including dieting, exercise, eating disorders, and even
substance use. For instance, growing rates of teenage smoking in girls has been linked to girls
believing that smoking will suppress their appetite, help them lose weight, and make them
feel better about their bodies (Wiseman, Turco, Sunday, & Halmi, 1998).
Body image plays a central role in some clinical disorders, including the eating disorders
and body dysmorphic disorder. The centrality of body image to anorexia nervosa was first
noted by Hilde Bruch (1962), who observed that anorexic patients felt that they were fat,
despite their objective emaciation. To consider eating disorders solely in terms of body image
disturbance oversimplifies the complex biopsychosocial nature of those conditions.
Nevertheless, much of the current research on body image is done with a view toward its
applicability for women who are struggling with clinical or sub-clinical eating disorders, or
body image disturbances (e.g., body dissatisfaction, drive for thinness).
BODY IMAGE ASSESSMENT

Body image assessment can be conducted for research or clinical purposes. This section
focuses mainly on body image assessment done for research purposes. As with all assessment
methods, the best instruments have demonstrated good validity and reliability. An exhaustive
review of the most commonly used body image assessment instruments is outside the scope
of this chapter, but the reader is directed to Cash and Pruzinsky (2002) for a thorough review
of the topic. Body image assessment approaches fall into three main categories, mirroring the
various dimensions of body image. First, cognitive and affective approaches (sometimes also
referred to as subjective measures of body image; Thompson, 1996) measure feelings and
beliefs about ones body shape or size (e.g., body dissatisfaction, drive for thinness). These
constructs are typically measured through self-report questionnaires or, less commonly,
through structured or semi-structured interviews. Behavioural approaches measure the
presence and/or extent of various behaviours intended to avoid or modify ones body size,
body shape, or weight (e.g., dieting, exercise). Such behaviours can be measured through self-
report methods (i.e. pencil-and-paper questionnaires) or through in vivo behavioural
experiments (e.g., experiments incorporating an eating task). Finally, perceptual approaches
focus on the accuracy of self-reported or estimated body size, shape, or weight. Such methods
include a) asking the individual for his or her self-reported weight and comparing that to their
objective weight, b) image marking (e.g., the respondent is instructed to draw or mark the
width of certain body parts), c) optical distortion (e.g., the respondent is shown a distorted
image of herself and is asked to adjust the image to match her perceived body shape and size),
and d) analogue scales (e.g., the respondent adjusts calipers or a beam of light to indicate the
width of certain body parts) (Farrell, Lee, & Shafran, 2005). Early body image research by
Slade and Russell (1973) devised a formula for what they called the Body Perception Index
(BPI = estimated size/actual size x 100), which quantifies the degree of over- or under-
estimation of body size. Factor analytic studies have confirmed these three dimensions of
body image (cognitive/affective, behavioural, and perceptual), and have shown that they are
related, but distinct from one another (Banfield & McCabe, 2002). In other words, there is
overlap, but not perfect agreement between observed results from the different body image
assessment approaches.
BODY IMAGE VARIABILITY

There is general agreement among researchers and clinicians that body image can be
conceptualized as both a state and a trait characteristic. Once considered to be static and
unmalleable, body image has now been found to be affected by numerous contextual factors
(Thompson & Gardner, 2002). It has been proposed that state body image is a reflection of
affective and cognitive factors, whereas trait body image encompasses an enduring cognitive
attitude toward ones body size and shape (Slade, 1994). This definition of state body image
can be seen as rooted in cognitive-behavioural theory. External events can trigger cognitive
processing about ones appearance and these cognitive processes can then trigger shifts in
body image perception and evaluation (e.g., Cash, 2002). The research to-date has supported
this view that body image reflects shifts in body-related cognitions. Affective evaluations of
ones body have been shown to fluctuate as a consequence of imagined situational contexts
(Cash, Fleming, Alindogan, Steadman, & Whitehead, 2002; Tiggemann, 2001), such as
imagining oneself in a bathing suit or while trying on clothes. In these types of studies, the
use of imagination creates an experimental analogue for real life situational contexts that
might trigger body-related cognitions. Other studies set up in vivo situations and measure
their effects on body image and its determinants. In a study by Wardle and Foley (1989), it
was shown that female participants felt fatter and less satisfied with their bodies after eating a
normal-sized meal (at least temporarilty), but the effect was more pronounced for dieters than
for non-dieters. This finding suggests that ones cognitive appraisal of food can affect body
image after eating. Another real life example of context affecting body image is pregnancy
(Johnson, Burrows, & Williamson, 2004). Over the course of pregnancy, a 30 lb weight gain
would probably elicit a very different reaction in a woman than would that same weight gain
in the absence of pregnancy. In addition to examples of body image variability in real or
imagined situational contexts, body image can even vary with the time of day (Melnyk, Cash,
& Janda, 2004).
When we examine group differences in the fluidity of body image, there is even more
evidence for intra-individual body image variability. In one study, hospitalized patients with
anorexia nervosa showed significant body image fluctuations across their four-week
hospitalization, but those fluctuations were only revealed when looking at individual analyses
rather than the group as a whole (Brinded, Bushnell, McKenzie, & Wells, 1990). Kulbartz-
Klatt, Florin, and Pook (1999) found that it was only women diagnosed with bulimia nervosa
whose body image changed as a result of an experimental mood induction. For those women,
but not the normal controls, negative mood elicited worsened body image and positive mood
elicited improved body image. Whereas the above mentioned studies sampled from clinical
populations, most of the empirical research on body image variability has been done with
female college-age participants. This is probably due, at least in part, to convenience
sampling. However, there is also a good theoretical rationale for studying young womens
body image. Certainly, women tend to focus more on their bodies than do men (Fanzoi,
Kessenich, & Sugrue, 1989) and generally express a more negative body image than do their
male counterparts (Polivy, Herman, Mills, & Wheeler, 2003). Furthermore, adolescence and
early adulthood are developmental periods that are especially related to heightened body
dissatisfaction in women (Polivy et al., 2003). There was one study that showed that male
participants body image was more consistent over time than was female participants body
image (Cash, Morrow, Hrabosky, & Perry, 2004a), although this was only a cross-sectional
study and not a longitudinal one. Therefore, we do not know from this study alone whether
men exhibit more within-individual instability in body image than do women. The question
of whether gender influences body image instability warrants direct study.
Taken together, the available research shows that a reliable predictor of intra-individual
body image variability is ones degree of appearance investment. Appearance investment can
be defined as the importance an individual places on her appearance in definition of her self-
worth. A commonly used index of appearance investment is the Appearance Schemas
Inventory (ASI-R; Cash, Melnyk, & Hrabosky, 2004b). This measure assesses two
components of an individuals psychological investment in his or her physical appearance.
Self-evaluative salience reflects the extent to which individuals define or measure themselves
and their self-worth by their physical appearance. Motivational salience measures the extent
to which individuals attend to their appearance and engage in appearance-management
behaviours. While the term appearance investment does not specifically focus on
investment in body image, ones body is an important facet of appearance. In their study,
Melnyk et al. (2004) found that body image variability was predicted by investment in
appearance, along with disturbed eating attitudes, and appearance-fixing coping strategies.
Similary, Cash et al. (2002) found appearance investment to predict those participants whose
body image was most affected by the contextual induction of negative body image. In an
online study of body image variability, Rudiger, Cash, Roehrig, and Thompson (2007) found
that greater daily fluctuation in body image was correlated with greater investment in ones
appearance, as well as more body image-related cognitive distortions and more appearance-
related perfectionism.
A consistent, yet somewhat counterintuitive finding in the body image literature is that
although women generally tend to gain weight as they get older, their body image remains
relatively stable over their lifetime and body dissatisfaction may even decrease with age.
Tiggemann (2004) explains that rather than being distressed by naturally-occurring increases
in womens weight over their lifespan, women actually report that they place less importance
on body shape, weight, and appearance in middle-age as compared to when they were young.
Other facets of self-esteem are believed to become relatively more important to women as
they move from early to middle and late adulthood, including self-esteem related to their roles
involving motherhood, relationships, and work. Consequently, women are less bothered by
their weight as they age. In other words, age can be considered yet another variable that
contributes to intra-individual variations in evaluative aspects of body image over time. As
with moment-to-moment shifts in body image, these age-related changes seem to be mediated
by changes in appearance investment over the lifespan.
SOCIAL AND CULTURAL INFLUENCES ON BODY IMAGE

In addition to fluctuations in body image as a result of time of day, mood, or other
internal factors (e.g., personality, age), further evidence for the instability of body image
comes from studies showing that even short-term exposure to various social and/or cultural
variables can shift the ways in which people see and evaluate their own bodies. For example,
the mass medias promotion of thinness as an ideal body shape for women undoubtedly plays
a significant role in changing womens self-concepts of body image (Shaw, 1995). Many
women perceive discrepancies between their actual body size and their ideal body size, and
there is widespread agreement that these discrepancies exist, in part, because of the beauty
ideals perpetuated by the media. The body images that are routinely displayed in magazines,
on television, and on film are unattainable for the vast majority of women (Greenberg,
Delinsky, Reese, Buhlmann, & Wilhelm, 2010) and can have adverse effects on body image.
Three key social and/or cultural variables that have been shown to affect body image and are
related to body image instability are media exposure, feedback from others about ones
weight, and weight norms. In this section, we review the research related to how such
variables affect body image. The majority of this area of research has been done with young
women who do not have an eating disorder, but exceptions are noted below.
Exposure to Media Images
Correlational studies have consistently shown a positive relationship between naturally-

occurring, self-selected media exposure (i.e., exposure to idealized body images through
watching television, reading magazines, etc.) and various indices of negative body image
(e.g., Botta, 2003; Harrison & Cantor, 1997; Stice, Schupak-Neuberg, Shaw, & Stein, 1994).
Women who spend a lot of time consuming media that contain high levels of thin, idealized
female body images are also the ones who are likely to dislike their bodies and engage in
disordered eating behaviours. However, in contrast to the consistent finding of a positive
relationship between media exposure and body dissatisfaction from correlational studies,
experimental research on the short-term effects of forced media exposure has revealed very
mixed findings. In a typical experiment, a participant is shown a series of thin, idealized body
images from the media, ostensibly for market research purposes. Print media are most often
used, but some studies have used television program or music videos as media stimuli.
Following exposure to these images, various indices of the participants body image (i.e.,
perceived body size, ideal body size, body dissatisfaction) are measured. Several studies have
shown that media exposure leads to worsened body image (e.g., Hawkins, Richards, Granley,
& Stein, 2004; Tiggemann & McGill, 2004), whereas others have found that media exposure
leads to improved body image in certain individuals, including chronic dieters (Joshi,
Herman, & Polivy, 2004; Mills, Polivy, Herman, & Tiggemann, 2002). Differential cognitive
processing of media images appears to play an important role in determining the effects of
media exposure effects on body dissatisfaction. Specifically, active engagement in self-to-
image social comparison is predictive of higher levels of body dissatisfaction after viewing
thin ideal images (Tiggemann & McGill, 2004). In other words, if a woman is actively
engaged in comparing her body to the body of a model in a picture, she is more likely to feel
worse about her body than if she is focused on evaluating the picture in the context of
advertising effectiveness or the like. Thornton and Maurice (1997), as well as others, have
attributed this phenomenon to social comparative contrast effects. Contrast effects can be
either positive, such as when self-ratings of attractiveness are enhanced after exposure to
unattractive stimuli, or negative, such as when self-ratings of attractiveness are lowered after
exposure to attractive stimuli, like thin media images. Perceived attainability of thinness also
seems to play a role in whether women feel better or worse about their own bodies after
looking at thin media images. Women who believe that they can lose weight and be thin are
more likely to feel better about their bodies after looking at thin media images than are those
who believe that thinness is unattainable for them (Mills et al., 2002). In short, the effects of
short-term media exposure on body size perception and mood are complex and are probably
moderated by a myriad of individual difference variables. On the other hand, what is clear
from the previous research on this topic is that looking at pictures of thin, attractive models
makes women want to be thinner than they think they are (Mills et al., 2002). Clearly, looking
at pictures of models in magazines or watching television programs with very thin models
delivers a visual reminder of societys beauty ideals and has the power to change the way in
which a woman sees and evaluates her own body.
Weight-Related Feedback
Another situation that can elicit a shift in the way in which a woman perceives or
evaluates her body is one in which she receives feedback about her weight. A common place
example of receiving weight-related feedback is stepping on a scale. Individuals with eating
disorders often discuss how stepping on the scale and seeing a number higher than they
wanted can profoundly affect not only their body image in that moment, but their mood and
self-esteem. Even for non-eating-disordered individuals, the scale can provide seemingly
objective evidence around which body image is constructed. Trying on clothing can also be
used to judge the size and shape of ones body. As is discussed in more detail in a later
section of this chapter, weighing, measuring, and using clothing to gauge the size and shape
of ones body can all be considered body checking behaviours. Such behaviours are readily
(and sometimes compulsively) used by individuals who are eager to receive input from their
environment that relates to body image. Without external and seemingly objective input like
stepping on a scale or trying on clothing, it seems that some individuals have a difficult time
gauging whether they have gained or lost weight. For many individuals, not knowing whether
their body size has changed can cause them significant anxiety.
In addition to these examples of objective weight-related feedback, including trying on
clothing and stepping on the scale, weight-related feedback can take other forms, including
receiving feedback about ones body from other people. Feedback from others about ones
weight can be considered a type of social influence on body image, as its impact is partially
dependent on valuing the importance of others perceptions of ones body (Schutz, Paxton, &
Wertheim, 2002). In one experiment, Mills and Miller (2007) investigated whether negative
verbal weight-related feedback has an effect on women in terms of their mood, self-esteem, or
body image. In their study, female undergraduate students either reported their current weight
(no feedback condition) or had their weight guessed as 15 lb higher than their actual weight
(negative feedback condition) by an experimenter who presented herself as either a peer or a
non-peer. Participants overall had higher anxiety and felt fatter in the negative feedback
condition. When this feedback came from a peer they felt fatter, more dissatisfied with their
bodies, and, for chronic dieters, more depressed, as compared to when the negative weight-
related feedback came from a non-peer. In sum, weight-related feedback either from an
objective source (e.g., a scale) or from a subjective source (e.g., a person) has the potential
to change the way in which we see and evaluate our bodies, and contributes to body image
instability.
Weight Norms
In an early and widely cited body image study, Fallon and Rozin (1985) investigated
mens and womens beliefs about the size of their bodies as well as their ideal body shapes. A
total of nearly 500 participants were asked to indicate on a continuum of nine male or female
hand-drawn silhouettes that ranged in size from extremely thin to extremely fat: 1) what they
perceived their current body to look like, 2) what they wanted their body to most resemble, 3)
the silhouette they believed would be most attractive to the opposite sex, and 4) which
opposite sex silhouette they would be most attracted to. The body shapes corresponding to
their current, their ideal, and the shape believed to be most attractive to the opposite sex were
very similar for men, revealing a high level of congruence between what men think they look
like and what they want to look like. Conversely, women perceived their current body shape
to be heavier than both their own ideal and the one they believed to be most attractive to the
opposite sex. Comparing across men and women, two other interesting findings emerged.
First, men believed that women wanted them to be heavier than they really did and, secondly,
women believed that men wanted them to be thinner than they really did. It appears that both
men and women judge their bodies not by medical or health norms, or even by feedback from
the opposite sex, but by sociocultural norms for their gender (Fallon & Rozin, 1985). The
Fallon and Rozin study, which has since been replicated with other samples and age groups
(Cohn & Adler, 1992; Huon, Morris, & Brown, 1990; Lamb, Jackson, Cassiday & Priest,
1993), is important because it was the first to demonstrate the discrepancies between what
people think their bodies look like, what they want them to look like, and what they think
they should look like to be considered attractive. This latter aspect of body image brings us to
an obvious question: Where do people get the idea of what they should look like? Where do
sociocultural norms for weight and shape come from? Certainly, the mass media play a role
in disseminating images that correspond to a beauty ideal, but these images largely represent
fantasy. Most people realize that magazine images of models are artificial (even digitally
mastered) and that they are presented for the purposes of inspiration or entertainment.
Furthermore, the media are as much a representation of sociocultural ideals as they are a
prescription of such ideals. On the other hand, do people use their perceptions of other people
around them real people to inform their ideal body size? And if so, does manipulating
perceived weight norms shift body image? It seems that the answer to both questions is yes.
In one experimental study, Dionne and Davis (2004) looked at the influence of body size
feedback on self-reported body dissatisfaction. Participants with normal body fat percentages
were randomly assigned to one of four feedback conditions: 1) told that their body fat was
lower than average, 2) told that their body fat was higher than average, 3) told that their body
fat was average, or 4) they received no feedback about their body fat. Participants who were
told that their body fat was either higher or lower than average reported more body
dissatisfaction than did those in either of the other groups. In another experiment, Mills,
Sieukaran, and Key (2010) recently investigated the effects of receiving information
regarding weight norms on body image. They tested 130 female students and delivered
weight norm information via the same silhouettes scale used in the Fallon and Rozin (1985)
study. In the thin norm group, participants were told that the average body shape was slightly
slimmer than the actual average. In the heavy norm group, participants were told that the
average body shape was slightly heavier than the actual average. Participants in the control
group received no information regarding the population average. Participants were then asked
to estimate their current and ideal body shapes. Controlling for participants actual body size
(as measured by body mass index; BMI=kg/m2), there was a significant main effect between
perceived weight norms and ideal body size. Individuals who were informed of a thin norm
reported a thinner ideal body size as compared to both the heavy norm and control groups.
Therefore, it appears that ideal body size is a socially constructed concept and is influenced
by beliefs about other peoples bodies and what is average. In other words, women want to
be thinner than most other women.
The combined research on social and cultural influences on body image clearly shows
that they can and do affect body image in women. The most reliable effect in this body of
literature is that social and cultural variables affect womens evaluations of their bodies. For
instance, reminding women of sociocultural standards and the beauty ideal by exposing them
to thin ideal media images shifts womens evaluations of their own bodies and makes them
want to be thinner than they think they are (and probably thinner than they really are,
although this has not been directly studied as a dependent variable of interest). Likewise,
women want to be thinner than most other women. There is special status ascribed to being
thin and thinness is one way for a woman to distinguish herself from the rest of the
population. We also see further evidence that evaluative aspects of body image are not fixed;
feedback from others has the potential to make us feel worse about our bodies. Interestingly,
no published research has shown the opposite effect that positive feedback from others
makes us feel better about our bodies, but this remains a plausible hypothesis. A less
consistent finding in this body of literature is that womens perceptions of their bodies change
as a function of social and/or cultural variables. However, we do sometimes witness body
image instability in the form of feeling thinner or heavier as a function of mass media
exposure and feedback from others about ones weight. This is especially true under certain
conditions, such as when the individual is a dieter or when weight-related feedback is coming
from someone who is socially connected to the individual (i.e., a peer), whose opinion
presumably counts for more than that of a stranger.
BODY IMAGE INSTABILITY: CAUSE OR EFFECT OF

APPEARANCE INVESTMENT?
Considering the literature as a whole, it seems that the more you care about your body
and appearance, the more unstable your body image tends to be. This is probably not just a
function of spending more time thinking about your body, since the frequency of body image
assessment in research studies is held constant across different groups of participants. Greater
instability in body image may reflect greater disorganization in body image. Whatever the
cause, instability of body image is probably not a good thing. In a similar way, instability in
ones sense of self has been linked to poor self-esteem (Campbell, 1990). Whether body
image instability occurs because of appearance investment or whether an insecure body image
drives people to invest more time and effort in their appearance (in order to try to achieve a
more stable and/or possible body image) has not yet been directly answered by the available
research. However, we propose here that one plausible explanation is that appearance
investment and its associated weight control behaviours (e.g., dieting, intense exercise, body
checking) can disrupt the formation of a cohesive sense of ones body at both a perceptual
and evaluative level. Habitual engagement in behaviours aimed at modifying ones body may
result in frequent shifts in the experience of ones body. Over time, this leads to chronic
shifting between feeling good (or at least neutral) and feeling bad about ones body. For
example, frequent exercisers often report that after working out they feel thinner, tighter, and
more toned. This result could be, at least in part, physiological and due to a temporary
increase in blood flow to the muscles, but it could also be a result of an increased sense of
well-being from exercise. In either case, the effect may only last a few hours. In the case of
dieting, extreme diets can lead to wildly fluctuating experiences of ones body ranging from
feeling thin and empty during a fast, to feeling stuffed after unwanted (but largely
inevitable) episodes of overeating or bingeing. In both cases, the result is an unstable sense of
ones body that, more frequently than not, results in an overall negative evaluation of the
body. Over time, an ongoing cycle of weight control and body image instability is
maintained. In summary, body image instability is probably both a cause and an effect of high
levels of appearance investment, but more research is warranted.
Body checking is an example of another behavioural aspect of body image and has begun
to receive more attention in the research and clinical literature. When body checking, the
individual engages in behaviours aimed at assessing the size, shape, or composition of her
body. Such behaviours can include looking in mirrors or window reflections, stepping on a
scale, looking at photographs, using hands or other objects to measure specific body parts,
and asking others to assess for visible weight gain or loss. Body checking is common among
individuals with eating disorders, but also occurs among non-eating disordered individuals.
Within a cognitive-behavioural framework, the act of body checking serves as an attempt to
reduce anxiety and to provide reassurance to the individual that she has not gained weight.
Over time, however, it can develop into a compulsive behaviour that perpetuates
dysfunctional cognitions about the importance of weight and shape and the consequences of
weight gain. Behavioural assessment methods for body checking include self-report
questionnaires and, more recently, the use of eye tracking devices. While it is typically
considered to be a behavioural aspect of body image, there are also subjective, cognitive, and
affective consequences of body checking. As with dieting and intense exercise, body
checking probably exacerbates body image instability through one or more possible paths.
First, recurrent body checking may strengthen appearance investment beliefs (e.g., It is
extremely important that I am thin). Second, by engaging in multiple or recurrent body
checking behaviours, the individual increases her chances of receiving conflicting or
contradictory feedback about her body (e.g., getting a different weight reading on different
scales, looking different in different mirrors), thereby adding confusion to the perception of
her body. We will revisit the concept of body checking in a later section, as it relates to
perceptual aspects of and attentional biases toward ones body.
BODY IMAGE ACCURACY

A corollary of the finding that there is considerable intra-individual variability in body
image is that people, at least some of the time, are not very accurate at estimating what their
bodies look like. As mentioned earlier, there are extreme examples of body image distortion
among individuals with an eating disorder, particularly in cases of anorexia nervosa. Here, we
review some of the literature pertaining to body image distortion, including among non-
eating-ordered individuals, and consider some of the possible theoretical explanations.
One of the most straightforward ways in which to measure an individuals degree of body
image distortion is to compare that individuals self-reported weight with her actual weight.
The validity of this approach as an operationalization of body image distortion rests on two
assumptions: 1) that people are able accurately match what they think their bodies look like to
a number (in lb or kg), and 2) that they actually believe the number they report. These
assumptions may or may not be reasonable, as discussed later. However, if we accept these
assumptions, it appears that people are generally inaccurate in estimating the size or weight of
their own bodies. However, the research findings are very mixed. One reason for these mixed
findings is the large discrepancy between the weight estimation findings for individuals with
anorexia nervosa and for those either with a different eating disorder (e.g., bulimia nervosa)
or without an eating disorder. Interestingly, individuals with bulimia nervosa most resemble
normal controls in terms of weight estimation. As discussed throughout this chapter,
individuals with anorexia nervosa are anomalous in the extent of their body image
disturbance. They also show a general ambivalence toward treatment and a strong resistance
to weight gain (APA, 1994). As expected, most individuals with anorexia nervosa
significantly overestimate their weight (Meyer, Arcelus, & Wright, 2009a). It is generally
understood that this distortion reflects a true belief within the anorexic woman that she is
heavier than she really is, but there are also other possible motives. In clinical observation, we
have seen patients with anorexia nervosa over-report their weight, even immediately after
being weighed, apparently so as to appear healthier than they really are and/or to justify
continued attempts at food restriction. Gardner and Bokencamp (1996) have suggested that
patients with an eating disorder do not have difficulty detecting change in body size, but
rather they have adopted a response bias that they believe they are larger than they actually
are. Clearly, there are complex and sometimes conflicting motives among individuals with
anorexia nervosa a compulsion to lose weight, a desire to convince others that they are
healthy, an extreme fear and avoidance of weight gain, and a desire to justify their disordered
eating to others. As a result, it is difficult to tease apart these possible motives and to fully
explain why individuals with anorexia nervosa overestimate their weight to the extent that
they do.
Most of the empirical research on body image accuracy has been on non-eating-
disordered young women, mostly college-aged. For the most part, this body of research has
found that women generally underestimate their weight (e.g., Christman, Bentle, & Niebauer,
2007; Ezzati, Martin, Skjold, Vander Hoorn, & Murray, 2006; Gorber, Tremblay, Moher, &
Gorber, 2007; Larsen, Ouwens, Engels, Eisinga, & van Strien, 2008; Meyer, McPartlan,
Sines, & Waller, 2009b). On the other hand, there is other research suggesting that women are
reasonably accurate (i.e., within five pounds) at estimating their weight (e.g., Cash, Grant,
Shovlin, & Lewis, 1992; Liechty, in press; Shapiro & Anderson, 2003). As is the case in a lot
of psychological research, we then turn to individual difference variables as possible

predictors of self-reported weight inaccuracy. Predictors of body weight underestimation
include: higher dietary restraint (McCabe, McFarlane, Polivy, & Olmsted, 2001; Shapiro &
Anderson, 2003), a larger discrepancy between actual and ideal weight (Doll & Fairburn,
1998), heavier actual weight (Cash et al., 1992; Christman et al., 2007; Ezzati et al., 2006;
Larsen et al., 2008), greater body dissatisfaction (Elgar, Roberts, Tudor-Smith, & Moore,
2005), and higher levels of weight concern (Meyer et al., 2009b). Moreover, every study to-
date examining potential gender differences has found that women have a stronger tendency
to underestimate their weight than do men (e.g., Christman et al., 2007; Gorber et al., 2007;
Ezzati et al., 2006). Taken together, a consistent picture emerges whereby individuals who
have heightened concerns about their body weight are the ones who are generally
underestimating their weight. This conclusion seems more plausibly linked to a psychological
explanation of weight underreporting than to a perceptual bias. This question was tested
directly in a study by Vartanian, Herman, and Polivy (2004). It was concluded that peoples
tendency to underestimate their own body weight is due to motivational rather than cognitive
or perceptual biases, as participants were generally accurate at guessing an unknown
individuals weight. As well, in that study, the standard predictors of weight underestimation
(e.g., weight concern, female gender) were not associated with weight underestimation of
others bodies, which, again, suggests that there is nothing faulty about those individuals
ability to judge the size and weight of bodies (Vartanian et al., 2004). Rather, it is probably
something about the meaning of the number that motivates people to underreport their weight.
Weight underestimation could reflect self-deception (e.g., I really am that thin), anxiety
reduction (e.g., It makes me feel better to think thats what I weigh), impression
management (e.g., I dont want people to know what I really weigh), or a combination of
all three. Whatever the motive underlying weight underestimation, there is at least some
evidence that people can self-correct these distortions under certain conditions. For example,
in one study, underestimation of weight was shown to occur to a greater extent when
participants reported their weight over the phone as compared to when they had to report it in-
person to the researcher (Ezzati et al., 2006).
In addition to the examination of the accuracy of self-reported weight, body image
distortion research has made use of computer-based assessment methods. Several relatively
recent body size estimation studies have used various software programs to digitally
manipulate photographic images of the participants and have participants either estimate the
amount of distortion or identify their true unaltered image (e.g., Hennighausen, Enkelmann,
Wewetzer, & Remschmidt, 1999). Older body size estimation methods included a technique
in which participants were asked to move two beams of light projected onto a screen to
estimate the width of their bodies or body parts (e.g., Ben-Tovim, Walker, Morray, & Chin,
1990). What is striking about the findings of both types of body size estimation studies is
their stark contrast to those of studies using weight estimation methods to assess body image
distortion. Whereas self-reported weight estimation methods yield the general finding that
women underreport their weight, body size estimation methods consistently find that women
significantly overestimate the size of their bodies (Bergstrm, Stenlund, & Svendjehll, 2000;
Birtchnell, Dolan, & Lacey, 1987; Cullari, Vosburgh, Shotwell, Insodda, & Davenport, 2002;
McCabe, Ricciardelli, Sitaram, & Mikhail, 2006; Shafran & Fairburn, 2002). Men also show
a tendency to overestimate their body size; the gender differences in body image distortion
studies are much smaller than are those found in weight estimation studies. As would be
expected, individuals with anorexia nervosa show even greater body size overestimation than
do normal controls (Smeets, Smit, Panhuysen, & Ingleby, 1998). In an experimental study by
Mussap, McCabe, and Ricciardelli (2008), a nonclinical sample of women was shown a series
of full body photographs of themselves that had been manipulated to appear either wider or
thinner than the original in random order over three separate trials. Participants who were
higher in dietary restraint, had greater eating concerns, and had greater body dissatisfaction
were even more likely to overestimate their body size than were those who scored low on
those measures. In other words, as with body image instability, we see that body image
distortion is related to personality characteristics indicative of appearance concern and
investment.
In order to try to make sense of the large disparity between the findings of weight
estimation studies and body size estimation studies, it is worth revisiting the assumptions of
those different methods. As mentioned earlier, the validity of the weight estimation approach
to operationalizing body image distortion rests on the assumptions that 1) people are able to
accurately match what they think their bodies look like to a number (in lb or kg), and 2) they
actually believe the number they report. In the case of the first assumption, it may not be true
that everyone knows his or her weight, or that they can accurately match their perception of
their bodies to a weight estimation number. If it has been a long time since a person was last
weighed, she may be inaccurate because she genuinely does not know her weight. By
contrast, almost everyone confronts their visual image on a daily basis, in mirrors, reflections,
or photographs. It thus seems reasonable to expect that people would be more familiar with
their image than with their weight (unless they weigh themselves very frequently and look in
the mirror very infrequently). So in this case, people should generally be more familiar with
their body size than with their weight. Thus, body size estimation may be the more valid
method of the two. In the case of the second assumption - that people actually believe the
number they report - a rival hypothesis is that they are providing a number that sounds
better to them, or one that they think will make a better impression on other people (i.e., the
researcher). As well, there may be more implicit demand characteristics in an experiment
employing weight estimation versus body size estimation. This is especially true if
appropriate methodological steps are taken in order to reduce demand characteristics in body
size estimation studies. These steps would include randomized and counterbalanced ordering
of the altered images of the participant, so as to reduce the likelihood that the participant will
deliberately choose a body size she knows is not accurate.
In summary, the bulk of the research evidence for the prevalence of body image
distortions comes from weight estimation studies. Women, more so than men, generally
underestimate their weight by more than five pounds. This finding most likely reflects a
motivational bias, but could also be due to individuals genuinely not knowing their true
weight. Evidence from body size estimation studies is more convincing, given that these
studies are generally less vulnerable to threats to experimental validity. The results from body
size estimation studies also show that individuals, even those without an eating disorder,
display significant body distortions. However, in contrast to the results from weight
estimation studies, most individuals overestimate their actual body size, indicating that they
are larger or heavier than they really are. Whether this should be considered a perceptual
bias is debatable and will be considered in the next section.
PERCEPTUAL ASPECTS OF BODY IMAGE

Given that it is accepted that body perception is a component of body image, but in light
of the large amount of evidence that body image is, in fact, neither stable nor accurate, it is
reasonable to question the perceptual aspects of body image. Just how good are we at
perceiving our bodies? Slade (1994) has suggested that body image is in fact not a true
perceptual phenomenon, but rather a loose mental representation of the body that is
influenced by at least seven sets of factors, including a) history of sensory input to the body
experience, b) history of weight change/fluctuation, c) cultural and social norms, d) individual
attitudes to weight and shape, e) cognitive and affective variables, f) individual
psychopathology, and g) biological variables. Smeets (1997) would agree, adding that body
image should really be considered a top-down process, with thoughts, cognitions, and
emotions impacting perception, rather than a bottom-up process, in which a true body
image becomes distorted later on. This top-down processing may be particularly true for
individuals with anorexia nervosa, whose body perceptions are grossly inaccurate and are
likely to reflect exaggerated expectations and past experiences with their bodies (Epstein,
Wiseman, Sunday, Klapper, Alkalay, & Halmi, 2001). Humans generally do not possess a
photographic memory and mental images stored in the brain may be quite poorly formed. As
a result, our mental comparisons of our bodies as we see them now to what we remember
them looking like a day, a week, or a year ago are probably not very precise at all. Consistent
with this idea, Auchus, Kose, and Allen (1993) found that individuals who exhibited
significant body image distortions also scored poorly on mental imagery, suggesting that
those individuals had a general inability to form and to use mental images. In other words,
body image distortion is not so much a problem with perception, but with mental imagery.
Like the experience of seeing ones body, the storage of those mental images of the body
can also be affected by emotions, expectations, and past experiences.
Attentional bias is an event that can bridge the gap between perception and emotion.
Perhaps an increased attentional bias toward thin bodies contributes to higher levels of body
image distortion. If you tend to focus only on thin people around you it may lead you to feel
bigger than you really are, in comparison to them. However, it appears that everyone pays
more attention to thin bodies than to heavy ones. Using a dot-probe perceptional task, it has
been shown, for example, that people generally show a faster reaction time to thin bodies than
to fat ones (Glauert, Rhodes, Fink, & Grammer, 2010). Instead, it appears that it is attentional
bias to your own body that contributes to body image distortion. Research on eye-gaze has
revealed some fascinating findings on individual differences that are linked to attentional bias
toward ones body. An early study by Freeman, Touyz, Sara, Rennie, Gordon, & Beumont
(1991) examined eye-gaze direction among participants who were shown a picture of
themselves. Non-eating disordered control participants exhibited a relatively even gaze
distribution among their various body parts. By contrast, individuals with an eating disorder
spent less time looking at their faces and more time looking at the body parts they had
expressed the least satisfaction with. In other words, individuals with an eating disorder were
visually fixated on the very body parts they disliked the most. Similar results have been found
by others, including the findings that obesity (Gardner, Morrell, Watson, & Sandoval, 1990)
and a higher drive for thinness (Hewig, Cooper, Trippe, Hecht, Straube, & Miltner, 2008)
predict attentional bias toward parts of the body commonly associated with weight gain, such
as the stomach, hips, and arms. Recently, Jansen and colleagues have replicated and extended
these findings in their lab (Jansen, Nederkoorn, & Mulkens, 2005). While looking at pictures
of themselves, individuals with an eating disorder showed decreased attentional focus on the
body parts they find attractive and increased attentional focus on the body parts they find
unattractive. This pattern was reversed in non-eating-disordered individuals. At the same
time, while looking at pictures of others, individuals with an eating disorder showed increased
attention to the attractive parts of others and less attention to the unattractive parts of others.
One of the consequences of this attentional bias is believed to be a lack of a self-enhancing
body image in individuals with disordered eating; they come to believe that most other people
have beautiful bodies and only they have an ugly body (Jansen, Smeets, Martijin, &
Nederkoorn, 2006). Even more concerning is that it is not just individuals with a clinically
significant eating disorder who show these self-defeating attentional body biases. Even
individuals from a non-clinical population with a higher BMI and low appearance self-esteem
paid more attention to self-identified unattractive body parts and others most attractive body
parts than they did to their own attractive parts and others unattractive parts (Roefs, Jansen,
Moresi, Willems, van Grootel, & van der Borgh, 2008).
Thus, it seems as though attentional bias is a perceptual element of body image that can
affect body image stability and accuracy. There has been virtually no research on the origins
of attentional bias, but the results of at least one study suggest that attentional bias toward
body cues in ones environment can be the result of other body-related behaviours. A recent
study by Smeets, Tiggemann, Kemps, Mills, Hollitt, Roefs, and Jansen (in press)
experimentally induced body checking by having female participants estimate the size of
some of their own body parts. Participants in the control conditions either were simply
exposed to their own bodies by standing in front of a mirror or were asked to estimate the size
of neutral objects beside them, such as a chair or desk. Participants in the body checking
condition reported feeling more dissatisfied with their bodies after the manipulation than did
participants in the body exposure and control conditions, demonstrating that body checking
can shift ones evaluation of ones body. However, it was also found that participants in the
body checking condition showed an attentional bias toward body-related information on a
subsequent cognitive task as compared to participants in either of the other two conditions.
These results are among the first to experimentally establish the link between body checking
and attentional bias toward body-related cues in the environment.
In summary, cognitive neuroscience research has concluded that body image perception
is mostly a top-down process, influenced by expectations, cognitions, and emotions about
ones body. We know that body image involves a memory for what the body looks like and
humans ability to properly form and access these mental images has been questioned (see
also Shafran & Fairburn, 2002). However, visual perception still plays a vital role in body
image distortion. Specifically, attentional focus on specific body parts appears to play a role
in the development and maintenance of body image distortions. There is objective and
reliable evidence that individuals who exhibit a negative body image are visually fixated on
the parts of their bodies they dont like. They spend considerably more time looking at these
self-identified unattractive body parts than they spend looking at the rest of their bodies.
Furthermore, they show the opposite pattern of attentional bias toward others bodies they
fixate on others beautiful parts and ignore their flaws. The result is a distorted sense of
both what they look like and what is achievable by most other people. Certainly, emotional
and/or psychological factors such as appearance investment could be linked to body-related
attentional biases. The more important your body is to you, the more you might pay attention
to it (and, as a consequence, the more unstable and inaccurate your body image is apt to be).
As has been reviewed, there is some preliminary evidence (Smeets et al., in press) that body
checking behaviours can cause body-related attentional biases.
CONCLUSION
In this chapter we considered the psychology of body image and analyzed the concepts of
body image instability and distortion. Body image is a multidimensional construct with both
trait (enduring) and state (moment-to-moment) components. More and more, researchers are
discovering that state body image may be even more important than trait body image in
predicting behaviour and emotions. It appears that body image is in constant flux and can
change as a result of many influences. Some of the influences on body image stability are
internal and some of them are external to the individual. In particular, research has shown that
peoples perceptions and/or evaluations of their bodies can shift under a variety of
circumstances, including imagined situational contexts (e.g., imagining oneself in a body
conscious environment), eating a meal, the time of day, getting older, feeling sad or
depressed, being exposed to thin media images, receiving feedback about ones weight, and
receiving information about what m ost peoples bodies look like. It is a reliable finding that
individuals who report high levels of appearance investment experience more body image
instability than do those who report low appearance investment. These individuals are also
more vulnerable to the effects of several of the general influences on body image instability
mentioned above. Satisfaction with ones body seems to be an especially malleable aspect of
body image; we most often see shifts in body dissatisfaction as a result of these afore
mentioned influences on body image stability. However, we also sometimes see shifts in
individuals perceptions of their bodies, wherein people will report feeling thinner or fatter as
a result of such influences. What is clear is that the more you care about your body and your
appearance, the less stable your body image is. It is not yet entirely clear whether body image
instability is the cause or the effect of high appearance investment, but it may be both. We
propose here that appearance investment and its associated behaviours (i.e., chronic dieting,
intense exercise, body checking) can disrupt the formation of a cohesive sense of ones body
at both the perceptual and evaluative levels. The result is that an individual frequently shifts
between feeling g ood (or at least neutral) and feeling
bad about her body.
Given that we are intimately familiar with our own bodies and that almost of us regularly
encounter images of our bodies in mirrors, reflections, and photographs, one might assume
that we would have a relatively good sense of what our bodies look like. On the contrary, it
seems that people generally do not have an accurate sense of what their bodies look like.
Extreme body image distortions among individuals with anorexia nervosa are well
documented, but even non-eating-disordered individuals are relatively inaccurate at
estimating their body size. Whereas individuals with anorexia nervosa typically overestimate
their weight, most individuals without an eating disorder underestimate their weight. This is
especially true for individuals who score high on dietary restraint and body dissatisfaction,
who are overweight, and who are female. In these cases, weight underestimation is not
believed to be perceptual in origin because these individuals are able to estimate others
weight reasonably accurately. It is more likely that weight underestimation represents a

motivational or impression management bias. In stark contrast to the weight estimation
studies, body size estimation studies reveal that people generally overestimate their body size.
There are smaller gender differences with body size estimation than with weight estimation
results. Factors predicting body size overestimation include weight concern, dietary restraint,
and body dissatisfaction. Body size estimation studies are probably a more valid way of
assessing body image accuracy than are weight estimation studies. In terms of perceptual
aspects of body image, there is support from the field of cognitive neuroscience for the view
that body image is a top-down perceptual process. In conclusion, people generally exhibit
what we call here poor body acuity, meaning that they demonstrate both body image
instability and body image distortion. There is little evidence of any type of perceptual
dysfunction underlying these phenomena. However, there is some evidence that cognitive
factors play a significant role. Specifically, attentional biases toward your own body appear to
contribute to body image distortion. The more time you spend focused on your body and the
parts you dont like, the more likely you are to experience body image distortions. Further
research is warranted to fully explain this relation.
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Chapter 4
MEASUREMENT OF THE PERCEPTUAL ASPECTS

OF BODY IMAGE
Rick M. Gardner and Dana L. Brown

Department of Psychology, University of Colorado Denver, USA
ABSTRACT
Body image disturbance (BID) is an important aspect of several pathologies in
psychology, particularly eating disorders. BID is commonly thought to include two
components; a perceptual component and an attitudinal component. The perceptual
component refers to how accurately individuals perceive the size of their body, also
known as body size estimation or BSE. The attitudinal component refers to the thoughts
and feelings one has about the size and/or shape of their body, which is also known as
body dissatisfaction. While both components have been shown to play an important role
in eating disorders, they are largely independent of each other. This chapter reviews the
clinical relevance of measuring BSE in relation to eating disorders and provides an
overview of research findings. A broad historical overview is provided that highlights the
various techniques that have been developed to assess BSE including analogue scales,
image marking, optical distortion methods, and figural drawing scales. Analogue scales
require participants to adjust the horizontal distance of a pair of calipers or two points of
light to show the width of various body parts. Image marking procedures require
participants to draw their body on a vertically mounted piece of paper or to mark on the
paper the width of certain body parts. Recent optical distortion methods typically employ
computer software that presents the participant with an image of themselves that has been
distorted in width and participants are asked to adjust the image to match both the actual
and ideal size of their body. These images are typically static digital images, although
photographs have occasionally been used as well. Each method is discussed along with
any relevant limitations or methodological concerns. Psychophysical techniques such as
the method of constant stimuli, signal detection theory, and adaptive probit estimation are
described in relation to methodological concerns such as distinguishing sensory from
non-sensory components of BSE. Video distortion techniques that incorporate
psychophysical techniques appear to be the most precise for measuring BSE.
82 Rick M. Gardner and Dana L. Brown
INTRODUCTION
There has been a resurgence of interest in topics related to body image in recent years. A
search of the database PsychInfo from the American Psychological Association reveals over
16,000 articles or books published on this topic since 1960. Body image is considered a
multi-dimensional concept that includes perceptual, attitudinal, affective, and behavioral
dimensions. Body image disturbance (BID) includes two components; a perceptual
component as well as an attitudinal component. Slade (1988) defines body image as the
picture we have in our minds of the size, shape and form of our bodies and to our feelings
concerning these characteristics and ones constituent body parts (p. 20). By this definition,
the mental picture corresponds to the perceptual component or how accurately individuals
perceive their body size also called body size estimation (BSE). The thoughts and feelings
about the size or shape of ones body refer to the attitudinal component or body
dissatisfaction. Numerous studies have documented that the perceptual and attitudinal factors
are largely independent of one another (Cash & Green, 1986; Dolan, Birtchnell & Lacey,
1987; Garner & Garfinkel, 1981; Mable, Balance & Galgan, 1986; Gardner, 2001), meaning
that a person may perceive their body accurately (perceptual component), but may express
dissatisfaction with their bodys size and/or shape (attitudinal component). A possible
exception has been observed in eating disorder patients who frequently suffer both perceptual
size distortion as well as dissatisfaction about their body size and/or shape.
While acknowledging the multidimensional aspects of BID is important in understanding
BID and its role in eating disorder pathology, this chapter will focus exclusively on the
perceptual component or BSE. The chapter will discuss the importance of the perceptual
component in eating disorder psychopathology and will describe the various techniques that
have been used to measure BSE, with special emphasis on advances in psychophysical
techniques. Several important methodological issues related to measuring BSE are also
discussed and recommendations for measurement techniques are made.
CLINICAL RELEVANCE
BID is unquestionably an important aspect in eating disorder pathology. While it is
widely accepted that the attitudinal component or body size dissatisfaction is known to play a
prominent role, the role that BSE plays in these disorders remains somewhat more
controversial. Interest in the perceptual aspects of body image was heightened by the
observation of Hilde Bruch in 1966 that individuals with anorexia nervosa have a distorted
perception of their body size, with most such individuals overestimating their body size
(Bruch, 1966). Despite the fact that patients suffering from anorexia nervosa are severely
underweight, many patients insist they are fat. The fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association,
2000) formalizes the role of BID in diagnosing anorexia nervosa by noting these patients have
an intense fear of gaining weight or becoming fat, even though underweight and that they
have a disturbance in the way in which ones body weight or shape is experienced,
(including an) undue influence of body weight or shape on self evaluation (p. 589).
Measurement of the Perceptual Aspects of Body Image 83
A lack of consistency in findings along with methodological shortcomings led to a

general disinterest in BSE in the early 1990s (Hsu & Sobkeiwicz, 1991). Recent advances in
methodologies used to measure BSE has led to a reemergence of interest in the topic and
resulted in findings that this construct is important in eating disorder research (Cash &
Deagle, 1997). Three meta-analyses have confirmed the relationship between BSE and eating
pathology. Cash and Deagle (1997) found a moderate perceptual distortion effect size that
ranged from .61 to .64, with greater body-size overestimations by individuals with eating
disorders. Smeets, Smit, Panhuysen, and Ingleby (1999) found a medium mean weighted
effect size of .43, with individuals with anorexia overestimating body size. Finally,
Sepulveda, Botella, and Leons (2002) meta-analysis of 83 studies conducted between 1970
and 1998 also found that individuals with eating disorders overestimate their body size, with
an effect size of .55 for anorexia, 1.12 for bulimia, and 1.19 for bulimarexia.
One study found that body size overestimation is a predictor of prior treatment failure
(Casper, Halmi, Goldberg, Eckert & Davis, 1979). Other studies indicate body size
overestimation is related to a lack of clinical progress in treatment (Norris, 1984), early
relapse following hospitalization (Russell, Campbell & Slade, 1975; Slade & Russell, 1973),
and poor clinical outcome following treatment (Garfinkel, Moldofsky & Garner, 1977).
Several investigators have found that body size overestimation declines as eating disorder
patients gain weight (Crisp & Kalucy, 1974; Russell, et al., 1975; Slade & Russell, 1973),
although one investigator found no such reduction (Button, Fransella, & Slade, 1977). One
conflicting finding by Fernandez-Aranda, Dahme, & Meermann (1999) indicated that BSE,
measured with a video distortion technique, was not related to treatment outcome in 44
patients with anorexia nervosa. Similarly, Freeman, Beach, Davis, and Solyom (1985)
reported that body dissatisfaction, but not body size overestimation, was a significant
predictor of treatment outcome.
Skrzypek, Wehmeier, and Remschmidt (2001) concluded that, Although overestimation
of body size is not a universal symptom in eating disorders, this issue is interesting in terms
of prognostic and therapeutic implications . . . and remains a worthwhile approach to
assessing body image disturbance in eating disorders (p. 215). However, as Cash and Deagle
(1997) have noted, even larger effect sizes occur on body dissatisfaction measures, indicating
the importance of measuring both of these independent factors with the eating disorder
population.
MEASURING BODY SIZE ESTIMATION

Several different techniques have been developed since the late 1960s for measuring
BSE. Techniques have been designed to measure specific sites (hips, arms, etc.) as well as
whole body assessment. Hsu and Sobkiewicz (1991) have classified perceptual techniques
designed to assess BSE into one of three classes of methods; analogue scales, image marking,
and optical distortion methods. As figural drawing scales have recently emerged as a method
to measure BSE, this chapter will discuss this methodology as well.
Analogue Scales
Analogue scales require individuals to adjust the horizontal distance of two points of
light, a pair of calipers, or some similar technique to indicate the width of various body sites.
Some of the earliest research related to these methods was conducted by Shontz (1969), who
constructed an apparatus that required subjects to estimate sizes of body sites by setting
distances between two wooden collars on a horizontal rod. Typically, individuals were
covered with a drape so that they could not see their body. Individuals conducted
measurements of several body sites, including head width, forearm length, hand length, foot
length, and waist width. Individuals also judged the size of control objects using simple,
cylindrical wooden rods approximately the length of the respective body sites. Results
indicated that body sites were overestimated more than the neutral control objects.
Specifically, head width and forearm length were most often overestimated while hand and
foot lengths were underestimated. Women overestimated the width of their waist more than
men, a result subsequently duplicated by other researchers (Hester, 1970; Predebon, 1980a;
Predebon, 1980b). Shontzs finding (1969) that subjects were less accurate with BSE than
with control objects suggests that one may use different cognitive processes when judging
size aspects of ones body.
A later seminal study by Slade and Russell (1973) ignited a great deal of interest in the
role that BSE plays in eating disorders. These investigators used an apparatus referred to as
the movable caliper technique, a device that had two lights mounted on tracks that
participants adjusted to approximate the width of various body sites. Measurements were
compared to the actual body site dimensions as measured by body calipers. The difference
between estimated and actual widths represented an index of accuracy of BSE. They found
that individuals with anorexia nervosa overestimated their body sizes to a greater extent than
did a non-clinical sample. This finding served as the impetus for numerous additional studies
examining the role BSE plays in eating disorders, as well as other disorders.
A variation on the analogue technique is called the Body Image Detection Device
(BIDD) developed by Ruff and Barrios (1986). The BIDD utilizes an overhead projector with
a covering template so a narrow band of light is projected onto the wall. A second movable
overlay template adjusts the length of the light band. The band of light is adjusted to estimate
the width of five body sites, including face, chest, waist, hips, and thighs. Body image
distortion is a measurement of the extent to which the adjusted light beam exceeds the
subjects actual dimensions. Thompson and Spana (1988) developed a similar technique
called the Adjustable Light Beam (ALBA). The ALBA projects four light beams on a wall to
match the perceived size of cheeks, waist, hips, and thighs.
In general, body site measures have been shown to be both reliable and internally
consistent (Ben-Tovim, Walker, Murray, & Chin, 1990; Slade, 1985). Mizes (1991) reviews
reliability values for the BIDD and reported coefficient alphas of .90 - .93 and test-retest
correlations of .84-.92. Validity measures are often missing for these measures, with the
exception of the ALBA measure which had good validity with other measures of BSE.
However, Cash and Green (1986) and Mizes (1991) review studies that have raised questions
on the validity of the BIDD. Barrios, Ruff, and York (1989) reviewed studies using this
technique and concluded that, The BIDD body image measures lack . . . estimates of
convergence with other measures of body image, estimates of divergence with measures of
other constructs, and estimates of concurrence with measures of bulimic symptoms (p. 70).
Subsequent refinements in measuring BSE have led to the discontinuance of this technique.
Image Marking Method
Another procedure that was popular in some earlier studies of BSE was the Image
Marking (IM) method (Askevold, 1975). In this procedure, subjects are asked to draw their
body on a vertically mounted piece of paper or to mark on the paper the width of certain body
parts. Askevold (1975) reported good one-day test-retest reliability estimates for shoulder,
hips, and thighs, but reliability coefficients for chest and waist were poor. Later reviews of the
IM method have questioned its utility as a method of measuring BSE and in differentiating
eating disordered patients from controls. Data on the convergent or construct validity of IM
have been lacking (Bowden, Touyz, Rodriguez, Hensley, & Beumont, 1989; Cash & Brown,
1987; Slade, 1985). As a result of these findings, the IM method has been used infrequently in
recent years.
Optical Distortion Methods
Distorting Photograph
One of the earliest techniques for measuring BSE was the distorting photograph
technique, employed by Glucksman and Hirsch (1969). Subjects estimate their size using a
projected photograph of their body, which can be distorted along the horizontal axis with an
anamorphic lens. Garfinkel, Moldofsky, Garner, Stancer, and Coscina (1978) found that
individuals with anorexia had very similar size estimations before and after a high calorie
meal while normal controls were less similar. In addition, some individuals with anorexia
overestimated their body size. Using this same technique, Garfinkel, Moldofsky and Garner
(1979) examined the stability of perceptual disturbances in females with anorexia and normal
controls. The females with anorexia were found to overestimate body size more than controls,
with stable size distortions over a period of one year. Speaker, Schultz, Grinker, and Stern
(1983) studied 18 obese adolescent boys undergoing weight reduction at a summer camp.
BSE was assessed using the distorting photograph technique. Boys correctly estimated their
body size prior to weight reduction while underestimating after weight loss. These authors
contrast their findings with adults with juvenile-onset obesity who overestimated body size
after weight reduction. As with some of the aforementioned techniques, the development of
more technically sophisticated methods for distorting images has led to the discontinuation of
the distorting photograph technique in recent years.
Distorting Mirror
Another technique used in some of the earlier research on BSE was the distorting mirror,
consisting of a special full-length mirror of crystal glass quality which can be adjusted to
reflect the body of the observed on a distortion continuum ranging from extremely distorted
to completely undistorted (Traub & Orbach, 1964). Utilizing this technique Traub, Olson,
Orbach, and Cardone (1967) found a group of patients with schizophrenia were significantly
less accurate in estimating their body size compared to a group of controls. The patients with
schizophrenia were also less accurate than controls in judging the size of a rectangular frame.
Test-retest reliabilities for body size overestimation over a one week period for these patients
varied between .40 and .74, depending on the body region that was measured. Comparable
reliability values for control subjects were between .70 and .81 over a one month retest
period.
Cardone and Olson (1969) used this apparatus to compare BSE between a sample of
patients with hemiplegia, suffering from paralysis to either the right or left side of their body,
with a control group. There were no significant differences between the groups when
estimating their body size, although the control subjects were more accurate in judging the
size of a rectangular frame.
Brodie, Slade and Riley (1991) examined gender differences in body size perceptions
using this methodology. There were no significant differences between genders for perceived
size, although both genders perceived themselves as wider than their actual image. A later
study by Brodie, Bagley, and Slade (1994) found no differences between pre- and post
adolescent females with both groups being reasonably accurate in judging their body size.
Finally, Brodie, Slade and Rose (1989) found the distorting mirror to have only moderate
test-retest reliabilities ranging between .34 and .58 over a period of four days. Convergent
validity with a video camera distortion technique (described below) was poor. As with the
distorting photographic technique, more sophisticated methods of measuring BSE have
replaced the use of distorting mirrors use in recent years.
Video Distortion Technique

Allebeck, Hallberg, and Espmark (1976) pioneered the use of a TV system for the
assessment of BSE. A TV monitor was modified to allow the remote adjustment of the
height/width of an individuals image. The amount of distortion possible with this device was
limited to 20% and a succession of more sophisticated devices followed. Freeman, Thomas,
Solyom, and Hunter (1984) took a similar approach by modifying a video camera that
presented size distortions of the participants horizontal dimensions on a TV monitor. The
authors reported high test-retest correlations between .86 and .90 over a test-retest period
averaging 11 days. Convergent validity was demonstrated by comparing measurements with
the distorting photograph technique. However, as mentioned earlier, a study by Brodie et al.
(1989) indicated low convergent validity with the distorting mirror methodology. A study by
Gardner and Moncrieff (1988) employed a variation of this technique to compare BSE in
patients with anorexia and controls. A TV camera was again modified so that the horizontal
dimensions of the participants image could be altered so as to cause the resulting body image
to appear wider or thinner while the height of the image was unaffected. Participants viewed
their image on a monitor and adjusted the width of their image by turning a potentiometer.
Probst, Vandereycken, Van Coppenolle, and Pieters (1995) used a similar approach only they
projected the images on a life size screen. Test-retest reliability was very high after both 15
minutes as well as a 10 day interval.
The widespread adoption of personal computers in the 1990s led several investigators to
develop software programs that permitted a wider range of distortions and also increased
measurement accuracy of BSE. Static images of individuals are downloaded into a computer,
which permits distortion of the horizontal dimensions of images. Subjects view their images
on a TV monitor or life size screen and are able to distort their images wider or thinner by
pressing buttons on a computer mouse. Typically, subjects adjust their image to the size they
perceive themselves to be as well as to the size they would like to be ideally. The discrepancy
between what the subjects perceive themselves to be and their actual size based on the static
image is a measure of body size distortion. The discrepancy between the size of the perceived
image and the ideal image is considered a measure of body dissatisfaction.
Early versions of this software usually allowed only adjustment of the horizontal
dimensions of an individuals body but later versions allowed for the adjustment of individual
body sites, thereby altering body shape. Hennighausen and Remschmidt (1999) developed
video distortion software that uses silhouette drawings created from photographs of
individuals frontal and side views. This program permitted measures of body size estimation
of the body regions of lower leg, thigh, hip, waist, chest, neck, and head.
Harari and Furst (2001) developed a computer-based method for the assessment of body
image distortions in eating disorder patients. Participants use a graphical user interface to
adjust their body shapes until they meet their self-perceived appearance. Aleong and
Duchesne (2007) subsequently developed similar software allowing manipulation of frontal
and side views of adolescent bodies. Individual body sites, including shoulder width, waist,
hip, belly, thigh and calf sizes, can be manipulated.
Stewart, Williamson, Smeets, and Greenway (2001) also developed a computerized
system for assessing body image in an obese female population. Two female human figures
were photographed in leotards and were edited to blur the face of the individuals. Morphing
software was used to create a movie clip consisting of 50 frames of figural stimuli, with
figures varying in size from thin to obese. Subjects were asked to project, via imagery, their
own face on the figure. They viewed the frames one at a time and selected the view that best
represented their current size, their ideal size, and what they judged to be their reasonable
size. Test-retest reliabilities over two to four weeks ranged from .66 to .91. Data on
acceptably high content validity and convergent validity are also given.
Sands, Maschette, and Armatas (2004) developed video distortion software that permits
participants to adjust their horizontal dimensions on chest, waist, hips, thighs, and calves to
measure size distortion as well as body dissatisfaction at these sites. A sophisticated
morphing technique adjusts the image to a realistic view of the body shape as the width of the
body sites are adjusted. Construct validity was demonstrated by the significant relationship
between scores obtained with a figural drawing method and those obtained using their
computer manipulation method.
Shafran and Fairburn (2002) developed a digital photography method for assessing
accuracy of BSE. A digital photograph of an individual is projected onto a screen so that the
individual can compare their actual reflection in a mirror to the projected image on the screen.
The authors claim that the procedure is designed to assess perception of body size as opposed
to a memory for body size. Data on significant convergent validity are given.
Gardner and Boice (2004) also developed software for measuring body size distortion
and body dissatisfaction. A static digital image of the participant can be presented on a
computer monitor or projected life size on a screen. The width of the static digital image can
be manipulated using any of three separate psychophysical methods including the method of
adjustment, staircase method, or adaptive probit estimation procedure (APE). In the method
of adjustment, the participant adjusts the image wider or thinner to match his or her perceived
size. The discrepancy between the perceived and actual size is a measure of body size
distortion. Participants may also adjust their image to the size they would like to be ideally,
with the discrepancy between the perceived and ideal size being a measure of body
dissatisfaction. In the staircase method, participants see an image that is continuously
expanding or contracting. The participants change the direction of the distortion when the
image matches their perceived size. An average of overestimations and underestimations at
each direction change is computed and serves as a measure of BSE. In the APE procedure,
participants judge whether a series of static images are distorted too wide or too thin. Analysis
of the responses permits a determination of the point of subject equality (PSE) and the
difference limen (DL). The PSE reflects the participants subjective judgment of their body
size and is a measure of BSE. The DL reflects the amount of body size distortion necessary
for the participant to detect the distortion 50% of the time. The authors maintain that these
two values are reflective of the sensory and non-sensory components that contribute to body
size judgments. This software has been used to measure BSE for both specific body sites as
well as the whole body (Gardner & Bokenkamp, 1996).
The Gardner and Boice (2004) program, including earlier versions of the software, has
been used successfully in a variety of populations, including obese individuals (Gardner,
Martinez, & Espinoza, 1987; Gardner, Martinez, Espinoza, & Gallegos, 1988), individuals
with eating disorders (Gardner & Bokenkamp, 1996), and children (Gardner, Sorter, &
Friedman, 1997; Gardner, Friedman, Stark, & Jackson, 1999; Gardner, Stark, Friedman &
Jackson, 2000). The staircase method has been demonstrated to be successful in measuring
body image in children as young as five (Gardner, Urrutia, Morrell, Watson, & Sandoval,
1990; Gardner et al., 1999).
An ongoing longitudinal study using this software is currently being conducted
measuring body size distortion and body dissatisfaction in 67 females with anorexia nervosa
(Fier, Hagman, Gralla, & Gardner, 2010). Preliminary findings indicate that patients with
anorexia perceived their body size as 10.4% larger than it actually was while desiring an
average body size 6.8% smaller than their actual body size, a 17.2% discrepancy reflecting
body dissatisfaction. Anorexic patients could detect 2.3% change in their body size, a finding
which is comparable to that found in earlier studies with non-eating disorder patients, and
further confirms that body size distortion in these patients is a result of cognitive/affective
factors and is not a sensory deficit.
Convergent validity of APE and the method of adjustment was demonstrated (Gardner,
Jones, and Bokenkamp, 1995) and also between APE values obtained with this software and
values derived from the BIAS-BD figural drawing scale (Gardner & Brown, 2010a). A more
detailed description of the psychophysical procedure APE that is employed by this software is
included later in this chapter.
Figural Drawing Scales

Figural drawing scales, sometimes also called silhouette scales, are line drawings of the
human form ranging in size from thinner than normal to wider than normal. Traditionally
these scales have been used to assess the attitudinal component or body dissatisfaction, but
more recently scales have been developed to assess BSE as well. Each scale contains a
discrete number of drawings, typically between 5 and 12. Individuals are asked to select the
figure that most closely resembles their current size as well as the size they would like to be
ideally. The difference between the current size and ideal size figures is a measure of body
dissatisfaction. The difference between the selected current size figure and the participants
actual BMI is a measure of body size distortion. A large number of these scales have been
developed in recent years, including scales specifically designed for children, obese
individuals, and ethnic groups.
Williamson and his colleagues were the first to use figural drawing scales to measure
BSE (Williamson, Davis, Bennett, Goreczny, & Gleaves, 1989). They developed a nine figure
scale ranging from thin to obese for measuring BID, including body size distortion in normal
weight control subjects and those with eating disorders. By using T-scores with a mean of 50
and a standard deviation of 10 their scale was able to determine a standardized score to
compare individuals judgment of their body size against the average of the comparison
sample. The authors state that this measure should not be considered a direct measure of body
size distortion, as it is interpretable only by comparing an individuals scores to those of the
control group (i.e. non eating disorder subjects) of similar height and weight. Williamson,
Womble, Zucker, Reas, White, Blouin, and Greenway (2000) later used a similar approach in
developing an 18 figure drawing scale for obese individuals with BMI values up to 50. Both
of these scales have very good reliability and validity.
Gardner, Stark, Jackson and Friedman (1999) also developed a scale to measure body
distortion and well as body dissatisfaction. Two figural contour drawing scales were created
using a frontal view photograph of an adult male and female with height and weight of the
median American. A two-figure analogue scale was created by distorting these drawings
30%. The resulting scale consisted of these two distorted figures connected by a continuous
horizontal line. Participants place a vertical mark on this horizontal line indicating their
current size as well as the size they would like to be ideally. Body size distortion can be
determined by where the vertical mark is placed relative to the two distorted figures. In
addition, a 13-card scale was created by generating 13 drawings distorted between 30% by
increments of 5%. Both scales have acceptable validity and reliability characteristics and
offer the advantage of allowing the estimation of individuals body size over- and
underestimation.
A recent approach to measuring both body dissatisfaction and size distortion with a
figural drawing scale was taken by Gardner and his colleagues (Gardner, Jappe, and Gardner,
2009). Seventeen male and female contour-line drawings were constructed using known
anthropometric body dimensions of shoulder, chest, waist, hip breadth, thigh breadth, and
upper leg breadth. The drawings correspond to a series of body weights ranging from 60%
below the known US average to 140% above average. Differences between figural drawings
represented a 5% change in body weight. Test-retest reliability after two weeks ranged from
.72 to .86. The scale had good concurrent validity, measured as the correspondence between
perceived and reported size. Because each figural drawing is based on known anthropometric
dimensions, calculation of body size distortion is relatively straightforward. A recent study
compared the amount of body size distortion and body dissatisfaction obtained with this scale
as compared to the Gardner and Boice (2004) video distortion software. Findings indicated
that participants overestimate their perceived body size more when using the figural drawing
scale (Gardner & Brown, 2010a).
Only one scale with documented psychometric properties has been developed for
adolescents, specifically students in the ninth through twelfth grades, which measures both
body dissatisfaction and size distortion (Peterson, Ellenberg, & Crossan, 2003). These
researchers created a 27 item interval scale referenced by 4 male or 4 female silhouettes. The
silhouette figures were generated from a Canadian Dietetic Associations scale of BMI-based
silhouette figures. Each figure represents a specific BMI value and each scale unit represents
an increase or decrease of one BMI unit. As with other figural drawing scales, subjects are
asked to select a rating of the size they perceive they currently are as well as the size they
would like to be ideally. The subjects rating is then translated into an equivalent BMI for that
subject. Good test-retest reliability was demonstrated for both genders as well as current and
ideal body sizes. Good reliability between ethnic groups was also shown, as was reliability
between grade levels. Perceived BMI values were significantly higher than actual BMIs for
both males and females, indicating body size overestimation for both genders.
Several investigators have noted numerous methodological problems with the use of
figural drawing scales (Thompson & Gray, 1995; Gardner, Friedman & Jackson, 1998;
Gardner & Brown, 2010b). These shortcomings include scale coarseness, restriction of range,
and method of presentation.
Scale coarseness refers to limiting response options to a finite number of drawings,
typically 5 to 12 figural drawings. Information is lost when a coarse response scale is used
to represent a continuous variable. Restriction of range refers to the phenomenon that most
subjects responding to a figural drawing scale will select their choice from amongst a small
subset of the figures. Gardner, Friedman, and Jackson (1997) found that children ranging in
age between 7 and 14 selected more than 85% of their choices from among only 3 of 8
possible silhouettes.
Method of presentation refers to the fact that most investigators present the figural
drawings on a single sheet of paper with figures arranged in ascending size from left to right.
Gardner et al. (1998) argued that such techniques would likely produce spuriously high test-
retest reliability estimates because the participants can easily remember which figure they
marked on the first measurement. In addition, Doll, Ball and Willows (2004) demonstrated
that different results are obtained when the figures are presented in ascending order of size as
opposed to being placed randomly on a sheet of paper. Further complicating this matter is the
finding by Nicholls, Orr, Okubo, and Loftus (2006) who found a spatial bias on responses to
Likert-type scale with a bias to respond to the left of the scales midpoint when values are
placed in an ascending order. This finding would suggest individuals will respond with a bias
toward thinner figures when viewing a scale in ascending order of size.
Finally, only a few of the dozens of existing scales have measures of reliability and/or
validity (Thompson & Gray, 1995). Gardner and Brown (2010b) have recently reviewed the
psychometric properties of the few scales designed for children and adults that report
reliability and/or validity.
PSYCHOPHYSICAL TECHNIQUES FOR ASSESSING BODY IMAGE

Methodological Issues
Although BSE is generally agreed to be an important component of eating disorders, the

research literature in this area has been marked by inconsistent findings, as was noted earlier.
Fonagy, Benster, and Higgitt (1990) note the numerous failures of replication that
characterize this literature. Slades (1985, 1988) reviews of this literature suggested that it
was the heterogeneity of techniques used in measuring BSE that accounted for these
inconsistent findings. It seems probable that different methods measure different aspects of
body image; specifically, the attitudinal and the perceptual components.
Fonagy, et al. (1990) also speculated that the cause of the inconsistent findings was due
to the sensitivity of the techniques used to measure situational factors. Technological
improvements such as the development of video distortion techniques went part way towards
solving these problems. However, Fonagy et al. (1990) believe that the cause was more likely
. . . . to lie in the sensitivity of the techniques used to determine situational factors such as
the demand characteristics of the experimental situation and the interaction of these with
clinical and personality factors (p. 160). Specifically, the earlier studies failed to distinguish
between perceptual sensitivity of subjects to detect distortion in their body size and the
response bias that is a result of non-sensory influences, such as attitudes, motivation,
expectations, etc., collectively referred to as the non-sensory aspects.
Beginning in the late 1980s, investigators looking at the perceptual and affective aspects
of body image disturbance began to employ more sophisticated psychophysical techniques.
Psychophysics is the scientific study of the relationship between the physical aspects of a
stimulus and the sensations and perceptions evoked by these stimuli. Some of these
psychophysical techniques offer the advantage of allowing the separate measurement of the
sensory and non-sensory components of BSE.
Within the context of body image research, the sensory component refers to the responses
of the visual system, including the retina and visual cortex, while the non-sensory
components, also referred to as the cognitive or affective components, reflect how the brain
interprets the visual input. The cognitive or affective component usually manifests itself in
dissatisfaction with ones body size or shape. Subsequent research with more sophisticated
psychophysical techniques has indicated that these two factors are largely independent of one
another. That is, a person can have a distorted image of their body size and suffer no body
dissatisfaction or conversely can be dissatisfied with their body without any concomitant
body size distortion.
Almost all the earlier techniques for assessing BSE accuracy, with the exception of the
IM and figural drawing scales, require subjects to make judgments of their body size on both
an ascending and descending series of trials. On individual trials, a subject typically sees a
representation of their body (video image, mirror image, light beam, two separate lights, etc.)
that is either too thin or too wide and he or she is required to make adjustments until the
image represents the perceived size of his or her body. On ascending trials the initial
representation is too thin and the subject adjusts the stimulus wider, while on descending
trials the initial representation is too wide and the subject adjusts the stimulus thinner. In most
instances the subjects adjusts the body representation although occasionally the experimenter
does so.
Several investigators have noted that the initial stimulus that is observed serves as an
anchor that greatly influences the final size judgment (Probst, et al., 1992; Gardner, 1996).
Numerous investigators including Gardner and his colleagues have consistently found that
subjects who are decreasing an initial image that is too large (descending trials) will reach a
final judgment of their body that is too large, and while increasing an initial image that is too
small (ascending trials) will reach a judgment that is too small. This is an example of how a
subjects expectations might possibly influence their judgment of their body size, as perhaps
expectations or anticipations are different when increasing a too thin image as compared to
shrinking a too wide image. It is also likely that different cognitive processing is occurring
when making an image of yourself wider as compared to thinner. Complicating matters

further, the amount of distortion reflected by ascending and descending trials is not the same,
with more accurate judgments typically being made on ascending trials. Most researchers
simply average the results of the ascending and descending trials but this simple calculation
of an average results in a value that does not accurately reflect what occurred on either series
of trials. As some of the earliest researchers in psychophysics noted, factors such as
participants attitudes, motivations, expectations, etc. regularly influence their judgments
about aspects of a stimulus (Gescheider, 1976). These factors were collectively referred to as
errors of anticipation. These errors affect the non-sensory or affective component of BSE and
not the sensory component, giving further justification for measuring each of these
independent components separately.
In recent years investigators have used several psychophysical methods to avoid errors of
anticipation and to separately measure the sensory and non-sensory components. These
methods include the method of constant stimuli, signal detection theory, and adaptive probit
estimation.
METHOD OF CONSTANT STIMULI.

One methodology to avoid these problems while measuring both the sensory and non-
sensory components independently is the method of constant stimuli (MCS). In this method,
ascending and descending trials are not used, thereby avoiding errors of anticipation. Instead,
a range of discrete stimuli (typically between five and nine different values) are used
repeatedly throughout the experiment. Within the context of body image research, these
stimuli include representations with no distortion as well as representations with distortions
that range from those that can be rarely detected to those that can nearly always be detected.
On a given trial one of these distortions is presented and the subject reports whether it
represents an over or underestimation. A table of the cumulative values of reported
overestimations results in the creation of an S-shaped (ogive) psychophysical function with
the subjects BSE being the point on the function where the subject reports 50% of the images
as overestimation and 50% as underestimations. This value is known as the Point of
Subjective Equality (PSE) as it represents the body size the subject judges to be subjectively
equal to their actual size. Any discrepancy between the PSE and the subjects actual size is a
measure of body size distortion. Additionally, the MCS allows for a determination of how
much body size distortion beyond the PSE is necessary before the subject reliably detects the
changes. This value is known as the Just Noticeable Difference (JND) or more frequently as
the difference limen (DL). Within the context of body image research, the PSE reflects the
non-sensory or attitudinal aspects of BSE, while the DL indicates the perceptual or sensory
ability to detect size distortion. As noted earlier, the sensory and non-sensory components are
considered to be independent of one another.
The earliest study that utilized the MCS in studying body image was conducted by
Gardner, Morrell, Watson, and Sandoval (1989) who examined PSE and DL values in obese
and normal weight individuals. Subjects viewed static images of their body at 11 discrete
levels of distortion ranging between 20%, with a 4% distortion separating each interval (i.e.
-20%, -16%, -8%, -4%, 0%, 4%, 8%, 12%, 16%, and 20%). Subjects made 50 judgments
regarding whether each image was "too wide" or "too thin" at each of the 11 intervals of size
distortion. There were no significant differences between obese and normal weight subjects
with the combined groups having a PSE of -0.62%, indicating that when subjects saw
themselves 0.62% thinner than they actually were they judged this image to be subjectively
equal to their actual size. The DL for the combined groups was 7.27%, which indicates that
the subjects had to see a distortion of 7.27% in their body size in order to reliably detect that
distortion 50% of the time.
Probst et al. (1995) used the MCS to compare the ability of individuals with anorexia and
bulimia as well as controls to detect distortion in the size of circles No significant differences
were found in DL values between the three groups, indicating no differential ability of the
three groups in sensory sensitivity to detecting distortion in a neutral object.
A recent study by Mussap, McCabe, and Ricciardelli (2008) using the MCS found female
college students overestimated their body size with an average PSE of 6.3%. They also found
an average DL of 3% across all subjects. Interestingly, they found the variability of PSE
values to be related to factors in disordered eating.
One disadvantage of the MCS is that it requires the presentation of many trials at several
different stimulus values. As a result, subjects find the task time consuming and burdensome.
As an example, in the Gardner et al. (1989) study, approximately 2 hours were required of
each subject to complete the procedure.
SIGNAL DETECTION THEORY

Signal detection theory was introduced in the 1950s by Tanner and Swets (1954). They
proposed a theory of signal detection that accounted for sensory and non-sensory factors
separately. A complete explanation of this theory is beyond the scope of this chapter but can
be found in any contemporary book on perception or psychophysics. Within the context of
body image research, a static image of a subjects body is presented that is either distorted in
size or is of normal size. Subjects are required to state on each trial whether the distortion is
present or absent. In body image research, body size distortion serves as the signal which
the subject is attempting to detect. The theory allows for the independent measurement and
separate computation of sensory sensitivity (d) or non-sensory response bias (). In this
instance, d' reflects the subject's sensitivity to detecting the presence of distortion in their
body. Response bias is the tendency for the subject to report that the viewed body image is or
is not distorted. Individuals with a low value are more likely to report that an image is
distorted, regardless of whether it is distorted or not. Similarly, higher values reflect a
response bias to report that distortion is absent.
Gardner and Moncrieff (1988) were the first investigators to apply this theory to studying
body size distortion. They compared subjects with anorexia with control subjects with no
history of an eating disorder. Subjects were shown static video images of their bodies that
were either distorted or not and they were asked to decide whether the image was distorted or
normal. Images were distorted both too large and too small by amounts of 3 percent, 6
percent, and 9 percent. Findings indicated no differences between subjects with anorexia and
controls as related to their ability to detect distortion of body size. However, on both too wide
and too thin distortion trials subjects with anorexia adopted a significantly more lax criterion
than the controls. This indicated that subjects with anorexia are more likely to guess that the
image of themselves was distorted (either too wide or too thin) as compared to control
subjects who were more likely to judge the images to be of normal size. This study was the
first to separate out the sensory (perceptual) and the non-sensory (affective) factors, and
contradicted the then prevailing opinion that individuals with eating disorders suffer from a
perceptual deficit. Rather, individuals with anorexia have a greater response bias to report that
size distortion is present, even when it is absent. This implicated the important role that
cognitive factors play in the perception of ones body.
In another study, Smeets, Ingleby, Hoek, and Panhuysen (1999) also used the MCS along
with a signal detection analysis to compare how females with anorexia estimate their body
size as compared to control groups consisting of both normal weight females and thin
females. Results indicated no sensory sensitivity (i.e. d') differences between the three groups,
suggesting that individuals with anorexia are no more sensitive in detecting distortion in their
body size than are females who are of normal weight or who are thin. In addition, no
significant correlations were found between BSE and perceptual sensitivity. Most
importantly, the subjects with anorexia showed a response bias (i.e. low values) to report
seeing "thin" differences, when comparing themselves with either an undistorted or too thin
image of themselves. The normal weight and thin females had the opposite bias; that is, a bias
to report seeing images as "too wide". Participants in this study also judged the body size of
persons in the other groups. The authors note that "Participants, in general, were more
accurate in detecting thinness in others, but fatness in themselves" (p. 476). The authors
concluded that women's concern for being thinner than others resulted in them having
heightened perceptual attention to the bodies of others. This led to more accurate visual
processing when participants saw widened pictures of themselves and thin pictures of
someone else.
A disadvantage of the signal detection methodology is the large number of trials
necessary to obtain stable values of d and . Green and Swets (1966) suggest around 500
trials should be used in a signal detection analysis but Gardner and Moncrieff (1988) found
that stable values were arrived at after only 100 trials, a finding corroborated by Smeets et al.
(1999).
ADAPTIVE PROBIT ESTIMATION.

As noted earlier in this chapter, Gardner and his colleagues have employed the use of an
advanced psychophysical technique called adaptive probit estimation (APE) to the
measurement of BSE and body size distortion. The use of this psychophysical methodology
for measuring body size was first proposed by Fonagy et al. (1990). Gardner (1996) described
this technique as follows:
APE is a psychophysical technique that estimates a complete psychometric function with

maximum statistical efficiency while using minimal participant labor. Briefly, the
experimenter estimates the mean and standard deviation of the error distribution for body size
estimates and presents four stimulus distortion levels at .45 and 1.35 z values. For
example, assume that a PSE of 0 percent body size distortion will be anticipated. Previous
research (Gardner, Morell, Watson, & Sandoval, 1989) indicated that the standard deviation of
obtained distortion values is 7.27 percent. Given these parameters, a participants video image
is presented at four levels of distortion: 9.81 percent too wide, 3.27 percent too wide, 3.27
percent too thin and 9.81 percent too thin. Eight blocks of 10 presentations of each of the four
distortion levels were used. The participant is required to judge whether each image is too
wide or too thin. Table 1 illustrates the percentage of wider than responses to the to the four
levels of body size distortion one would anticipate, while Figure 1 illustrates these values
plotted with a best fit cumulative normal sigmoid function. As with the method of constant
stimuli, the best fit psychophysical function reveals simultaneously the PSE and the difference
threshold. In this example the participant would have responded that an image distorted 0
percent would have appeared wider than his or her actual body size 50 percent of the time,
thus indicating a PSE of 0 percent. The standard deviation of the obtained wider than
percentages about the 50 percent point indicates the slope of the psychophysical function. A
larger slope (and correspondingly, a smaller standard deviation) indicates a greater sensitivity
to the participant to detect changes in stimulus size. The DL corresponds to the amount of
change in body size necessary for the participant to detect the change 50 percent of the time
and is illustrated in Figure 1 as those distortion levels corresponding to 25 percent and 75
percent too wide judgments. For the data illustrated in Figure 1, the PSE = 0 percent
distortion with a DL of 4.0 percent.
Table 1. Percentage of judgements too wide for body image distortion at four
levels of distortion
% Distortion % Judgements too wide

+9.81 95
+3.27 70
-3.27 30
-9.81 5
1
From Met hodological issues in assessment of the perceptual component of body image disturbance, by R.
Gardner, 1996, British Journal of Psychology, 87, p. 333. Copyright The British Psychological Society,
reprinted with permission.
From Me thodological issues in assessment of the perceptual component of body image disturbance, by R.
Gardner, 1996, British Journal of Psychology, 87, p. 334. Copyright The British Psychological Society,
reprinted with permission.
Figure 1. Best fit cumulative normal sigmoid curve for too wide judgments presented at four levels of
distortion. The PSE corresponds to the percentage of body size distortion where the participant made 50
per cent too wide judgments. The difference threshold (DL) reflects the amount of change in body
size distortion necessary for the participant to detect a change in body size 50 per cent of the time.
Thus far, the APE procedure can be seen to mimic closely the procedure used with MCS.
Where APE differs is that the four stimulus levels are subject to revision. At the end of the
second and every subsequent block, a rapid and approximate probit analysis of the last two
blocks is made. The four stimulus levels are then reselected as necessary on the basis of this
analysis (Watt & Andrews, 1981). If the obtained PSE is found to be not centered in the four
stimulus presentation values, then an appropriate adjustment is made in the subsequent four
distortion levels which are presented in the next block of trials. Similarly, if the four
distortion levels represented a task that was too easy or too hard for the participant, the
standard deviation of the subsequent distortion values would be adjusted to make the
difficulty of the discrimination more appropriate on the subsequent block. A complete and
immediate correction of the PSE and standard deviation to the stimulus testing set is not
made, as this makes the system too sensitive to transient changes in the participants PSE, and
so the formulas for generating subsequent stimulus levels have some inertia (see Watt &
Andrews, 1981, p. 208). After a series of such blocks, an average PSE and root mean square
standard deviation are calculated to reflect overall performance.
The standard deviation in APE is a measure of the participants sensitivity to detect
changes in body size and is a relatively unbiased indicator of sensory factors. In signal
detection theory terminology, the standard deviation of the psychometric function may be
regarded as analgous to d while the PSE gives an indication of response bias () (Gardner,
1996, pp. 333-334). 1
As noted earlier, Gardner and Boice (2004) developed a computer program using this
psychophysical technique for measuring both body size distortion as well as sensory
sensitivity for detecting body size distortion. A complete description of the software is
beyond the scope of this chapter and is detailed by those authors including sample output for
the method of adjustment, the staircase method, and APE. The body image software is
available from the first author.
CONCLUSION
The perceptual component of body image disturbance (BID) or body size estimation
(BSE) is an important topic related to eating disorder pathology. Interest in measurement of
BSE has fluctuated over time as a result of the challenges with measurement methodologies
and inconsistency in research findings. Advancements in psychophysical procedures to more
accurately capture the sensory component of BID have sparked renewed interest in
measurement of BSE. Researchers have uncovered some interesting findings supporting the
connection between BSE and eating disorder pathology, though some evidence remains
inconclusive.
This chapter has provided a broad historical overview of the various techniques that have
been developed to measure BSE since the late 1960s including analogue scales, image
marking, optical distortion methods, and figural drawing scales. Analogue scales require
individuals to adjust a horizontal distance of a pair of calipers or two points of light in order
to show the width of certain body parts. Image marking requires individuals to draw their
body on a vertically mounted piece of paper or to mark on the paper the width of various
body sites. Early optical distortion techniques include the distorted mirror, where an
individuals image is distorted on a continuum. In general, techniques such as analogue

scales, image marking, and the distorted mirror have been replaced with newer and more
precise optical distortion methods such as video distortion techniques that utilize computer
software. These programs typically present an individual with a distorted image of themselves
and they are asked to make adjustments to the image to demonstrate their actual size as well
as the size they would like to be ideally. Improvements to video distortion software have been
made through the application of more advanced psychophysical techniques such as the
method of constant stimuli, the signal detection theory, and adaptive probit estimation. These
methods have allowed investigators to address some important methodological issues in
measuring separately the sensory and non-sensory components of BID. The sensory
component refers to the responses of the visual system. The non-sensory component also
referred to as the cognitive or affective component, reflects how the brain interprets the visual
input.
Figural drawing scales have historically been used to assess the affective component of
BID also called body dissatisfaction. However, recently developed scales have the capability
to measure BSE and body size distortion as well as body dissatisfaction. Only some of these
scales have reliability and validity data and address methodological concerns raised by
researchers such as scale coarseness, restriction of range, and method of presentation. Figural
drawing scales provide a reasonable measurement option for researchers, and advantages of
the scales include the relatively short administration time and the fact they can be used to
collect group data. While the figural drawing scales may be a viable option, recent research
findings have concluded that the video distortion approach appears to offer a more precise
technique for assessing both body size distortion and body dissatisfaction. Researchers who
choose to use a figural drawing scale should select from among the relatively few that have
documented psychometric properties and that measure both body dissatisfaction as well as
body size distortion, as described by Gardner and Brown (2010b).
In summary, capabilities for measuring BSE have continued to evolve and improve, with
the help of psychophysical techniques and other advanced technologies. There are currently
more precise options for measurement of this construct than have been available to
researchers in the past, which may help facilitate increased research on BSE. Along with
improved measurement capabilities comes the potential for researchers and clinicians to
continue to explore BSE in relation to assessment, treatment, and recovery from eating
disorders and other related pathologies.
ACKNOWLEDGMENTS
Reproduced with permission from British Journal of Psychology The British
Psychological Society.
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Chapter 5
BODY IMAGE AND CANCER
zen nen Sertz*

Ege University School of Medicine
Department of Psychiatry
Division of Consultation Liaison Psychiatry
35100, Izmir-Turkey
ABSTRACT
The diagnosis and treatment of cancer can result both physical and psychiatric
morbidity. Physical and psychological changes during the course of cancer may alter an
individuals body image. Alterations in body image can contribute to the psychosocial
adjustment of cancer patients. Early studies investigating the role of body image among
cancer patients primarily have paid attention to breast cancer patients. The ongoing
studies than examined body image disturbances and factors associated with body image
changes in patients with different types of cancer.
In general factors related to body image changes in cancer patients are due to: 1)
cancer treatments (chemotherapy, radiation therapy, hormone therapy and surgery); 2)
results of treatments such as hair loss, weight loss or weight gain, loss of an organ, scars;
3) psychological distress related to cancer diagnosis, its treatments and cancer related
issues; 4) personality properties (those who place importance on their appearance are
more likely to experience distress when faced with a greater self-discrepancy in their
appearance; 5) gender (women are more prompt to have more concerns than men about
physical appearance; and 6) age. In addition to all these factors there is literature
knowledge that body image concerns can change in follow-up period of a cancer
diagnosis.
In this chapter, body image disturbances in cancer patients, factors related to body
image disturbances, body image disturbances in different types of cancer, impact of body
image disturbances on quality of life and sexuality will be discussed. Also treatment
approaches for body image disturbances in cancer patients will be reviewed in the light of
the literature.
* E-mail: onensertoz@gmail.com
104 zen nen Sertz
INTRODUCTION
There is a growing interest in body image across various research disciplines in recent
years. This led to emergence of new approaches to the definition and conceptualization of
body image. Fisher (1990) has stated that one also needs to recognize that there are indeed
quite different and perhaps largely independent dimensions represented under the rough
rubric of body image. There is no such entity as the body image (White, 2000). Therefore
researchers referring a common term as body image have studied different components of
body image. The term body image refers to ones feelings, perceptions, and attitudes towards
ones physical self, appearance, overall wholeness, functionality, and ability to relate to
others. Body image is also defined as a part of individuals self-worth (Kissane et al., 2004).
One of the important components of body image is self-appraisals or self-perceptions of an
individual. According to Whites heuristic cognitive behavioral model, body image overlaps
with self-perceptions or self-concept. According to this model individuals have self-schemas
as well as body image schemas that influence the processing information that results from
new situations like cancer that result with visible or non-visible differences in appearance or
in sense of integrity (White, 2000).
The disturbances in body image generally occur when there is a discrepancy between the
way one has formerly perceived himself/herself and how he/she now perceives
himself/herself after a serious illness (e.g. cancer) and associated treatments. However, Rosen
and colleagues (1993) found that 47% of healthy women are dissatisfied with their body
image.
In conceptualizing body image, Higgins has an important role. Higgins (1987) theory of
self-discrepancy has been successfully applied to body image studies and according to his
theory there are two states of self: ideal self and actual self. This theory emphasizes the
discrepancy between two states of self that can result in negative psychological states. In
other words if there is an actual/ideal self-discrepancy, this produces disappointment.
There is a relationship between the degree of self-discrepancy and the intensity of affect
that occur by the awareness of the discrepancy. After Higgins contributions about
ideal/actual selves, discrepancy between two selves and their relationship with body image
disturbances; Cash and Szymanski (1995) showed the importance of investment in body
image. For example an individuals perceived discrepancy may be present but the impact of it
can be insignificant or significant, which depends on the individuals degree of investment. If
the investment is little, then the impact of perceived discrepancy between ideal and actual
selves will be small.
As a result, to understand body image term with its components, which are mentioned
above, will enhance our understanding of why not all people are affected from cancer and its
treatments equally in terms of body image.
FACTORS AFFECTING BODY IMAGE IN CANCER PATIENTS

Body image changes due to cancer treatments can vary according to their duration and
intensity. Hair loss, weight loss or gain are usually temporary changes due to treatments
where else amputations such as limbs or mastectomies where prostheses can be fitted,
Body Image and Cancer 105
permanent stomas, infertility, scars from surgery or tattoo markings from radiation fields are
examples of permanent changes that can affect body image negatively. Both permanent and
temporary changes may or may not be visible to other people. Although some patients may
not notice any changes about their body perception when they face with physical changes that
are not visible to others, some of them may perceive body image disturbances. Because body
image relates to how you feel about your body and self.
Surgery
Surgery on the face or the parts of the body associated with sexual performance or
attractiveness has a more severe impact on self and body image than surgery on the hands,
feet, or back. Breast surgery in women and surgical treatment of prostate cancer in men are
often accompanied by changes in the patient's self and body image, particularly with respect
to sexual relations.
Radiation and Chemotherapy
Radiation and chemotherapy can affect a cancer patient's body image because they often
cause hair loss, radiation burns, and unattractive changes in the patient's complexion. While
hair loss caused by chemotherapy is usually a temporary condition, hair loss caused by
radiation treatment may be permanent. In addition, both radiation and chemotherapy can
cause nausea, vomiting, fatigue, depression, and other reactions that affect the patient's sense
of competence as well as their relationships with others. Self-image often suffers when a
person feels that job performance and valued relationships are being strained by these side
effects of cancer treatment.
Alopecia is another common side effect of chemotherapy. The loss of hair is a constant
reminder to a woman that she is living with cancer. She may also feel embarrassed because
she appears "different." In prospective randomized study chemotherapy induced alopecia was
investigated among 136 women in terms of self-esteem and body image. The patients were
randomized in to two arms as receiving a videotape intervention or not prior the course 3 of
chemotherapy. The authors found that chemotherapy induced alopecia-affected body image
negatively but a videotape intervention was not effective (Nolte et al., 2006).
CANCER TYPE AND BODY IMAGE

Breast Cancer and Body Image
Breast cancer is the leading cause of cancer among women and the second cause of
cancer deaths in women according to American Cancer Society data (Fobair et al., 2006). It is
also the most frequent cancer seen among women in Turkey (Haydaroglu & Ozsaran, 2005).
Survival rates from breast cancer have been increased. The five-year survival rate for women
of all stages is 86% and 96% for women with local stage disease (Fobair et al., 2006). In
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respect to these findings, examining psychosocial quality of life issues among breast cancer
survivors become one of the main targets of care. Therefore problems like body image and
sexuality, which may be altered by the disease and its treatments became one of the important
issues that can be faced by a woman with breast cancer in long-term period.
Cancer treatments may result in major alterations of body image in breast cancer through
loss of a body part, disfigurement, scars or skin changes. Radiotherapy may cause tissue
damage, which persists for many years. The effects of surgery are more immediate but often
permanent. Transient or reversible changes such as hair loss, weight gain or loss can be
results of chemotherapy. Breast cancer diagnosis and treatments can reduce womens body
image satisfaction. Women who receive breast conservation therapy that is the least invasive
type of surgery report that post-operative scaring led them to feel less attractive and to make
more negative judgments about themselves (Ogden & Lindridge, 2008).
In the study of START Trial Management Group, the effects of adjuvant breast
radiotherapy on patient-reported breast, arm and shoulder symptoms and body image have
been investigated. According to study results; a substantial proportion of women have
reported moderate or marked breast, arm and shoulder symptoms over five years of follow-up
after radiotherapy. But these symptoms did not lead to body image disturbances. In other
words in long term period (after five years from initial treatment) no change in terms of body
image was observed (Hopwood et al., 2010).
Up to date, numerous studies have found that mastectomy rather than breast conserving
surgery, young age at diagnosis, poor mental health related quality of life and psychological
distress are associated significantly with poor body image (Pelusi, 2006; Fobair et al., 2006;
Baucom et al., 2005-2006; Scott & Kayser, 2009). There are also some studies that found no
relationship among surgery types in terms of body image in breast cancer (Al-Ghazal et al.,
1999; Min et al., 2010).
In the study of Al-Ghazal et al (1999) in which the authors examined psychological
distress and body image changes with respect to surgery type in an experimental longitudinal
design found that there were no significant differences in terms of psychological distress or
body image between groups that did or did not undergo post mastectomy plastic surgery.
Recently, in another study a group of 236 women with a primary diagnosis of breast
cancer or carcinoma in-situ followed-up at six months and 12 months post surgery. The
authors found that the quality of life of patients improved over time, but impairments in terms
of anxiety, body image and sexual functioning were still observed. They also found that
younger women were more likely to be distressed by cancer diagnosis and treatment and that
the surgical modality played a minor role in quality of life (Hrtl et al., 2010).
In two studies conducted in Taiwan, it was found that breast cancer patients with breast
reconstruction surgery reported higher satisfaction with their new breasts and better quality of
life than patients who received mastectomy only (Liu, 2008).
Fobair et al (2006) have studied the body image and sexual problems in young women
with breast cancer with respect to impact of age to body image and sexuality have found that
i) body image and sexual problems were experienced by a substantial proportion of women in
the early months after diagnosis; ii) half of the patients experienced two or more body image
problems some of the time but at least one problem much of the time; iii) among sexually
active women, body image problems were mostly associated with mastectomy and possible
reconstruction, hair loss from chemotherapy, concern with weight gain or loss, poorer mental
health, lower self-esteem and partners difficulty understanding ones feelings; iiii) half of the
sexually active women reported having a little problem in two or more areas of sexual
functioning; iiiii) one of the reasons associated with greater sexual problems was having more
body image problems.
In another study Zimmermann et al (2009) have studied individual and dyadic predictors
of body image in women with breast cancer and found important findings. The authors have
mainly investigated the impact of individual factors such as surgery type, medical treatments,
disease stage, womens age, depressive symptoms and dyadic variables such as relationship
satisfaction and duration, dyadic coping on body image. Consequently they have investigated
the predictors of body image. In their study the authors have found that individual and dyadic
factors impact differently upon womens body image after breast cancer. Also they have
found that age was an important predictor for both aspects of body image and that depressive
state was an important predictor of body image in which self-esteem is usually decreased.
From this study we may conclude that self-concept of body image is very important in whole
evaluation of body image.
As a conclusion in breast cancer and body image literature, the evidence is equivocal as
to whether mastectomy, mastectomy with reconstruction or breast conservation therapy
impact differentially on body image. But in the long term it has been found that the type of
medical treatment seems not to have strong influences on body image (Kornblith & Ligibel,
2003). From existing literature knowledge we can also suppose that women who have body
image problems in the long term may have some other problems that have impact on body
image such as depression, personality properties, degree of investment in body image, and
baseline self-image of an individual.
In addition to these factors affecting body image there are some cultural issues, which
may impact the choice of treatment and body-self image changes due to breast cancer
surgery. With this respect in most developing and eastern countries especially
postmenopausal women with breast cancer undergo radical form of surgery. A study from
Egypt examined this issue and showed that even postmenopausal women with breast cancer
living in an eastern country and that were brought up in this culture had body image
disturbances related to surgery type. In this study postmenopausal women with breast cancer
who underwent modified radical mastectomy as compared with postmenopausal women with
breast cancer who underwent breast conservation surgery showed statistically significant
body image distress among cognitive, affective and behavioral aspects (Mohamed et al.,
2009).
In our study we found that women with breast cancer and had breast reconstruction
surgery had better body image and self-esteem than breast cancer patients who had total
mastectomy alone (Noyan MA et al., 2006). Turkey is located between Europe and the
Middle East; it combines a mixture of western and middle-eastern cultural values. The breasts
are a prominent symbol of femininity, but the emphasis placed on femininity is not highly
valued in traditional groups living in both rural and suburban areas. Overall, Turkish cultural
belief has negative attitudes toward preoccupation with femininity and especially a woman
is married, a mother, menopausal, or has had a mastectomy, society expects her to withdraw
her femininity. Although values and traditions are changing, such beliefs and cultural effects
are not changing as rapidly.
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Head and Neck Cancers and Body Image
Head and neck cancers account for only an estimated 3% to 5% of all cancers (Penner,
2009). As a result of the disease and effects of treatment on the functional integrity of the
head and neck region, patients with advanced head and neck cancer can experience profound
changes to fundamental and visible aspects of life.
Having cancer around the head and neck regions is a disfiguring experience. It is
different from other disfiguring conditions since it can not be camouflaged and is therefore
distressing condition that impacts significantly an individuals self image, body image and
relationship with others (Callahan 2004).
Health related quality of life studies conducted among patients with head and neck
cancers showed that patients had lower level of quality of life than normal population that
significantly deteriorate after treatment with the lowest level at 4-6 months after treatment,
then slowly improving after one year (Konradsen et al., 2009). Katz et al (2003) have reported
that patients reporting low health related quality of life were the ones with low levels of social
support and they were mostly women.
Surgery and radiotherapy are currently the main treatment modalities for head and neck
cancers. In head and neck cancers organ functions and appearance are damaged by disease
progression and cancer treatments. Treatment of advanced head and neck cancer has evolved
to include organ preservation in the form of combination of radiotherapy and chemotherapy.
This therapy assumed to preserve the function of the treated organ and decrease morbidity
associated with surgery and post-operative radiotherapy. Despite its main objective the organ
preserving treatments are still associated with severe treatment related adverse effects. In long
term care patients needs in terms of functional and psychosocial concerns arising from the
illness and associated treatments should be covered.
Reconstructive surgery of these region tumors primarily focuses on restoring local
function of the related organs and retaining a socially acceptable appearance after tumor
resection. However patients did not return to their prior functioning completely. In addition
patients face with the problems resulted from the effects of treatments in terms of appearance
even after three years following surgery (Lin et al., 2000; Epstein et al., 2001).
As valid for all cancers, the degree of distress is related to the degree of disfigurement
and impaired function. Body image concerns are also related to these factors. Patients with
head and neck cancers reported that they coped more easily with dysfunction than with
disfigurement (Mast 1999).
Application of new reconstructive techniques have resulted better body image outcomes
in head and neck tumors. Most of the patients with head and neck tumor reported a negative
change in their satisfaction with personal appearance after surgery (Lochart, 2000).
Despite the improvements in reconstructive techniques such as free flap repair, in general
they are not enough to fix disfigurement. Because the color and sheen of the donated flap are
different from that of the recipient site making local disfigurement obvious and not easily
hidden (Liu H-E, 2008).
As a result despite the improvements in reconstructive techniques dissatisfaction with
appearance is a common experience for head and neck cancer patients worldwide.
One of the important areas related to body image and functional changes in head and
neck cancers is the changes of working status. With this regard in the study of Liu (2008) 97
patients questionnaires with head and neck cancers were reviewed retrospectively and the
results of the study showed that; compared with pre-surgery satisfaction with personal
appearance did change negatively even after micro-reconstructive surgery had been
conducted. And also approximately 1/3 of the employed patients changed their jobs after
cancer treatments. The participants in this study declared that their major reason for job
change was discomfort caused by cancer treatment.
Clarke in his review emphasizes the importance of management of psychosocial
dysfunctions faced by patients with head and neck cancers and states that investigation of
facial disfigurement independent of medical diagnosis may help understanding patients
difficulties in social interactions (Clarke, 1999).
With this regard one study have investigated this issue and explored how disfigurement
was addressed in interactions between patient and nurse during the period in hospital
immediately after undergoing disfiguring facial surgery (Konradsen et al., 2009). In this study
the authors found that nurses tended to use implicit and unverified professional assumptions
about patients preferences and needs, which created a risk of not seeing an individual
patients specific needs. They added from this empirical study nurse-patient interaction
revealed that disfigurement was silenced in surgical facial cancer treatment. According to
their study the authors explained the process of silencing disfigurement as fallows: after a
patient had undergone treatment, the notion of disfigurement as a luxury problem persisted.
Centrally positioned, mute and unquestioned, seeing disfigurement as a luxury problem
formed a pattern together with minimizing disfigurement and another time, another place,
which triggered a silencing process. By not questioning the importance of disfigurement both
nurses and patients continued silencing the issue of disfigurement, but did so independently
of one another, since their assumptions were unchallenged and unverified by each other.
Consequently in head and neck cancers bodily functions and appearance are very
important domains of health related quality of life, emotional distress, social interactions and
long-term adjustment to illness and its consequences.
Gynecological Cancers and Body Image
This type of cancer includes the ovaries, uterus, endometrium, cervix, vagina, and vulva
and may involve the adjacent pelvic structures and lymph nodes. Surgery, chemotherapy,
radiotherapy or a combination of these modalities may be used to treat gynecologic cancers.
Surgery is often used to diagnose stage and treat gynecologic cancers. A total abdominal
hysterectomy or a radical hysterectomy is used to treat ovarian, uterine or cervical cancers. A
hysterectomy can affect a woman's psychological and emotional well-being. Women of
childbearing age have been found to experience sadness and anger at the loss of fertility, and
women of all ages view the loss of female organs as a loss of femininity (Steginga & Dunn,
1997).
Radical vulvectomy and pelvic exenteration are two extensive surgeries that dramatically
change a woman's physical appearance and alter her sexuality.
In most of the studies it was reported that treatment of gynecological cancers could result
in debilitating adverse effects that can be worse than the disease itself and have a significant
impact on a womans quality of life (Ferrel et al., 2003; Tabano et al., 2002). In gynecological
cancers common problem areas that were identified with prior studies were physical
symptoms such as severe neuropathy, pain, sexual concerns, symptoms of early menopause
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and fertility issues, gastrointestinal problems, fatigue, lymphedema, and numerous other
symptoms (Ferrel et al., 2003; Tabano et al., 2002; Donovan et al., 2005; Ryan et al., 2003).
Researchers have also documented a range of psychosocial needs such as psychosocial
distress after diagnosis, before and after surgical procedure, after treatments, or when facing
extensive chemotherapy and advanced disease; changes in body image; altered relationships
with partners and other significant persons in one's life; anxiety; depression; difficulties in
dealing with death or mortality; and loss of behavioral-emotional control. It has also been
suggested that physical impairment leads to psychological distress for these patients because
it erodes a sense of control (Lauver et al., 2007; Tabano et al., 2002; Ekwall et al., 2003;
Ekman et al., 2004; Glover et al., 2003).
During the postoperative period the patient will need help adjusting to her altered body
image. Many women will have to learn to care for a new colostomy or how to catheterize a
continent urostomy. Women who have had a vulvectomy will need sensitive counseling to
understand that she can still respond sexually. Patients who have had a vaginectomy with
reconstruction as part of a pelvic exenteration will need extensive teaching to help them
achieve successful sexual functioning.
Surgical and non-surgical treatments lead body image changes in gynecological cancers.
Although the disfigurements related to the surgery or other treatments in gynecological
cancers are not visible to others distressing body image changes are common in gynecological
cancers. Disfigurements are related to sexual organs and body image plays an important role
for many women in maintenance of sexual self-image. In addition to disfigurement many
symptoms or side effects of treatments such as pain, edema, weight gain or loss, symptoms of
early menopause and infertility may contribute negatively self-image and body image and
have long-lasting effects on the womans sexual confidence and in her intimate relationship
(Katz, 2009).
Patients also have concerns about sexuality and their relationships with their partners.
Surgery and radiation therapy usually lead vaginal constriction and this may cause tension or
pain during intercourse. Abdominal scars and surgical incisions can interfere with how a
woman views her body, making her uncomfortable in an intimate situation. The vaginal canal
may be shorter after a hysterectomy causing discomfort with sexual intercourse. However, the
elasticity of the vagina gives it the ability to stretch during intercourse. The removal of both
ovaries in a premenopausal woman will cause menopause or the lack of ovarian function. If
estrogen is not replaced, vaginal dryness and vaginal atrophy may be formed causing
discomfort with intercourse and pelvic examinations. All these sexual problems also have
impact on an individuals self- image and body image.
Body image is an important component of health related quality of life. In a recent study
560 patients were enrolled from a population-based sample of cervical cancer survivors and
the assessment of health related quality of life was aimed. According to study results the
patients greatest concerns were related to family/social and emotional well-being, body
image and sexual health. The major predictors of overall health related quality of life were
radiation, co-morbidity, role limitations, perceived health status, psychological well-being,
body image, sexual impact, doctor-patient relationship and social support (Ashing-Giwa et
al., 2009).
As a conclusion in gynecological cancers, treatments and their consequences lead major
problems in terms of body image and sexuality. Thus body image plays an important role for
many women in maintenance of sexual self-image (Lagana et al., 2001). These problems
affect health related quality of life and emotional well-being negatively. Therefore patient-
doctor and patient-nurse communication is very important in addressing problems that
patients face.
Prostate Cancer and Body Image
Prostate cancer is the leading source of solid organ cancer in men. The prevalence of the
disease increases over the age of 65 years. Survival rates are high when the disease is
diagnosed at early stage. The relative five-year survival rate is 98% and most men diagnosed
and treated for prostate cancer survive for many years. Psychosocial consequences of the
cancer become visible in long term. In prostate cancer, patients face the disease specific
treatment side effects such as urinary, bowel, sexual, hormonal dysfunction that ameliorate
mens physical, social and emotional functioning (Weber and Sherwill-Navarro, 2005;
Harrington and Badger, 2009).
Until the 1990s researches on prostate cancer have focused on primarily the surgical or
medical management of the disease and the treatment side effects that men face. Psychosocial
consequences of prostate cancer and the impact of the interventions focused on psychosocial
problems became to appear in the scientific literature in 1990s (Weber and Sherwill-Navarro,
2005).
The most common physical morbidity among prostate cancer patients was erectile
dysfunction, urinary incontinence and bowel dysfunction that negatively affected quality of
life. Mostly men who underwent radical surgery experienced erectile dysfunction. Erectile
dysfunction was reported to be related with low quality of life, low self-esteem and low
marital satisfaction. One another physical dysfunction is urinary incontinence that depends on
several factors such as stage and grade of the cancer, treatment and technique used and
patients age. Severe urinary incontinence was found to be related to depression, anxiety, low
self-esteem and quality of life (Krane, 2000; Powell, 2000; Herzog et al., 1988). In addition
bowel dysfunction related primarily to radiotherapy was found to be associated with low
quality of life.
One important point in prostate cancer is side effects related to androgen deprivation
therapy. About one-third of men in treatment are receiving androgen deprivation therapy.
Androgen deprivation therapy has deleterious side effects occur because of the reduction of
testosterone to castrate levels (Harrington and Badger, 2009). Related to decreased levels of
testosterone, patients with prostate cancer experience a variety of symptoms that can impact
patients physical, emotional and social lives. Physical changes include loss of muscle mass,
weight gain, and increase in adiposity and breast tenderness and enlargement. Also loss of
penile length and volume and loss of testicular mass have been reported (Frohmuller et al.,
1995; Hunt, 1997). Due to androgen deprivation therapy patients usually experience hot
flashes, fatigue, depression, osteoporosis, anemia and a decrease in high-density lipoprotein
cholesterol level (Weber and Sherwill-Navarro, 2005).
Beyond the well-studied literature on psychosocial, physical impact of prostate cancer on
patients lives or quality of life, there is lack of knowledge whether these changes lead body
image disturbances among prostate cancer survivors. According to Harrington and Badger
(2009) significant physical and functional changes in prostate cancer may have a salient
influence upon body image and important quality of life aspects. Their assumption bases on
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the evidence for such a relationship that have been shown in breast cancer by numerous
studies (Weber and Sherwill-Navarro, 2005). In their descriptive study they have explored the
relationship between changes in body image and quality of life among 132 men aged 60
years with prostate cancer whether or not on androgen deprivation therapy. They found that
there was a significant negative correlation between body image dissatisfaction and quality of
life. In another study the relationship between androgen deprivation therapy and body image
dissatisfaction was investigated. The authors found that patients receiving androgen
deprivation therapy for prostate cancer might be at greater risk of body image dissatisfaction.
As a result there is not enough knowledge about body image disturbance, its relationship
with factors such as cancer treatments, emotional well-being, personality characteristics or
marital adjustment in prostate cancer survivors.
Colorectal Cancers and Body Image
Colorectal cancer is the fourth commonest form of cancer worldwide. Curative surgery is
the main treatment approach and it is attempted approximately 80% of the patients. Adjuvant
radiotherapy and chemotherapy are the other options of treatment with surgery. Prognosis
varies with the extent of disease at diagnosis. The estimated overall 5-year survival rate for
early-localized disease is 90%, while the 5-year survival rate of the patients with metastatic
disease is 10%. Mortality rates have declined significantly due to advances in surgical
techniques and adjuvant therapy. Improvements in treatments and early detection of cancer
result with longer survival, thus it means more patients will live with the consequences of this
disease such as bowel function problems and its related psychological distress (Whistance et
al., 2010; Scarpa et al., 2009). Therefore quality of life issues and factors that have impact on
quality of life such as body image concerns, sexuality, social or physical functioning.
Anorexia, nausea and vomiting, weight loss, abdominal discomfort, diarrhea and
constipation can complicate psychosocial adjustment to colorectal cancers. Surgical scars,
stomas, odor and side effects of chemotherapy or radiotherapy can lead body image
disturbances and may result with social withdrawal (Massie & Greenberg, 2005).
In the study of Ramsey et al. (2002) colorectal cancer survivors were found to have a
relatively uniform and high quality of life, not related to disease stage and time since
diagnosis. Non-cancer co-morbid disorders and low-income level had more influence on
quality of life than stage or time since diagnosis. When compared with age-matched controls,
long-term survivors reported higher level of quality of life despite their higher rates of
depression. For many survivors frequent bowel movements and chronic recurrent diarrhea
were a problem.
In one study, assessment of body image in patients undergoing surgery for colorectal
cancer was investigated. The researchers tested the validity of 10-item body image scale
(BIS). The authors found that a nine-item scale assessing overall body image with a separate
single item, assessing dissatisfaction with the surgical scar (item 10), and they concluded that
it was the most appropriate questionnaire structure and with this form of the scale it showed
good reliability and clinical and psychometric validity. They recommended this form of BIS
for use in trials and studies specifically evaluating body image issues related to surgery for
colorectal cancers. In this study, patients with a stoma reported poorer BIS scores than those
undergoing simple resection (Whistance et al., 2010).
In the study of Scarpa et al (2009) the authors examined the effect of laparoscopic-
assisted surgery with open colonic resection in terms of quality of life, body image, cosmesis
and functional results. Patients who had laparoscopic-assisted resection stayed shorter in
hospital, reported better satisfaction with their own body than those who had open colonic
resection. The cosmetic score was significantly better in the laparoscopic-assisted group than
in the open group. Both patients group reported similar functional and quality of life results.
One of the most causes of body image disturbance in colorectal cancer is stoma
formation. Therefore more detailed information related to stoma formation and its
consequences will be discussed. As well established colorectal cancer is one of the most
common conditions that result with stoma surgery. Stoma formation usually results in
psychological morbidity. It is suggested that this may be exacerbated for those living in
industrialized countries where consumer culture provides multitude of styled images of body
(Brown & Randle, 2005).
In a systematic review Brown and Randle (2005) investigated the impact of stoma to
patients lives. They summarized the effects of stoma in terms of quality of, body image,
sexuality and psychosocial adjustment and coping. The studies examining the impact of
stoma on quality of life have revealed that stoma formation usually has a negative impact on
quality of life. In one study over the 50% of the respondents stated that having a stoma had
minimal or no effect on their ability to find work. But for the remaining sample over 20% of
the colostomists and 15% of the ileostomists responded that having a stoma meant they had to
totally change their work. Approximately 10% of the respondents had serious problems with
diet and clothing due to their stoma.
In another study all participants with stoma reported that their stoma had negatively
influenced their quality of life, body image and self-esteem (Persson & Hellstrom, 2002).
Brown and Randle (2005) in their review concluded that most patients experience
negative feelings after stoma formation in the short term and that these negative experiences
are dependent on the purpose for the stoma formation.
According to Salter (1997) body image is an important part of every day life and society
places enormous importance on having an attractive body. Therefore diseases resulted with
stoma formation produce body image disturbances.
In the literature most of the studies conducted on patients with stoma revealed that they
perceive body image changes as a direct result of their surgery. Women are more prompt to
experience body image related problems than men after a stoma surgery (Brown & Randle,
2005).
Jenks et al (1997) investigated the body image disturbances due to ostomy surgery among
patients with colorectal and bladder cancer. They assessed body image changes at times
presurgery one month after surgery and six months after surgery. The findings showed that
participants experienced body image change after ostomy formation. Body image scores were
lowest in the preoperative period than in the postoperative periods. The authors suggest that
body image improves as length of time from surgery increases. Because at the beginning the
major themes related to situation were uncertainty and hopelessness but after six months post
surgery patients whose cancer had not metastasized described a return to normal life. Patients
generally adapted their stoma.
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TREATMENT APPROACHES
Nurses can play a critical role in caring for patients who have body image disturbances
and need help. Active listening to patients, giving information about the side effects or
procedures and their results during and after treatment period is very important. When the
patients are given the information that they can understand, then they can be involved in their
decision making process. The literature suggests that patients inclusion in the decision
making process before treatments are started is an indication of adjustment (Brown & Randle,
2005).
After these important approaches are included in patient-nurse or patient-doctor
relationship we can identify patients difficulties in daily life functioning, social and
emotional functioning, in body image and sexuality due to cancer and cancer treatments.
Evaluating cancer patients with a quality of life instrument or a self-report questionnaire
to assess emotional distress will help health care professionals to address the problems
associated with cancer and its treatments. Then further evaluation can be applied according to
a patients need. Psychiatric evaluation may be required for some patients. Depressive
disorders, adjustment disorders and anxiety disorders are the most common psychiatric
conditions seen among cancer patients. To assess psychiatric disorders and to treat these
conditions are essential because they have negative impact on quality of life, body image and
sexuality.
Temporary body image changes due to cancer treatments like hair loss, can be covered by
a variety of wigs, partial hairpieces, and scarves or turbans. Doctors who specialize in plastic
surgery can suggest ways to treat facial scars or other types of surgical disfigurement,
including the loss of body parts. A prosthesis, which is an artificial replacement for a missing
or damaged body part, can be made to order for the patient.
Patients who have stoma need professional evaluation both pre and postoperatively.
Nurses can play an important role in caring for these patients. Nurses can help stoma patients
as fallows: i) helping the patient to adjust their diagnosis and prognosis, ii) adapting to life
with a stoma, iii) teaching practical skills in caring for their stoma, iiii) addressing issues
around family and support networks, employment, body image and sexuality (Baxter &
Salter, 2000).
According to related literature it is an essential need to be supported by professionals if
an individual experiences changes in body image after stoma surgery to a greater or lesser
extent. It is essential because poor psychosocial adjustment to stoma surgery was shown to
correlate to depression and predict death later on (Brown & Randle, 2005).
Cosmetic
Cosmetic rehabilitation is another approach for body image changes. Cosmetic

camouflage clinics use techniques from the theatre and cinema to hide a variety of non-lethal
skin conditions that significantly impair a patients appearance. In a study the effectiveness of
cosmetic rehabilitation program was investigated among oral cancer patients. One researcher
in this study was trained and certificated by an experienced physical therapist that had a
license in cosmetic rehabilitation and this researcher thought all of the cosmetic programs to
the patients that are in the experimental arm. Patients were given a free set of cosmetic
equipment, a manual for cosmetic makeup and a questionnaire (Multidimensional Body-Self
Relations Questionnaire Appearance Scales) for subjective evaluation. Patients took 6-12
weeks to integrate cosmetic rehabilitation into their lives. At the end of the study period
patients in the experimental and control arms did not show any significant change in terms of
body image scale scores but the results of item comparison showed that cosmetic
rehabilitation improved the scores I like the way I am, most people think that I am good
looking, body weight and face in the experimental group (Huang & Liu, 2008).
Counseling and Support
Up to date there is limited number of non-pharmacological studies conducted on patients

with visible disfigurements. The studies examined the efficacy of self-help materials, psycho-
education, cognitive behavioral therapy (CBT), group based or person centered therapies,
social skills training, support groups. These studies did not show the exact effectiveness of
those therapies (Penner, 2009).
Cognitive behavioral models are based on that as a human being we begin to process
information at the birth and continue till death. The nature and the results of these processing,
change from one individual to another and lay under the most of our psychological
experiences and automatic thoughts. When we face a traumatic event (it can be a loss of loved
one or loss of health or appearance due to a medical illness) our automatic thoughts or beliefs
reactivate and cause psychological disturbances. It is now well accepted that body image
problems are associated with poor self-esteem, social anxiety, self-consciousness and
depressive symptoms, cancer and cancer treatments (White, 2000; Sertoz et al., 2009).
Therefore body image is inseparable from feelings about the self. Heuristic cognitive
behavioral model of body image refers the importance of perceived self-ideal discrepancy and
investment in it (White, 2000). As a result a patient who has body image change (e.g., hair
loss due to chemotherapy) due to cancer or its treatments can either accept her appearance
and adjust to treatment because she gives little importance to her out-looking and have a
sense of self-worth or denies her appearance and can not accept it because she gives much
importance to her appearance and the investment in her body is big. Because of these reasons
body image researchers should assess body image with appropriate instruments that include
all dimensions of body image in cancer patients. In this regard, the most cancer specific body
image measures are The Body Image Scale (BIS; Hopwood, 1998), Body Image Instrument
(BII; Kopel et al, 1998) and Measure of Body Apperception (MBA; Carver et al., 1998).
There is a plenty of literature indicating the efficacy of CBT on depression, anxiety or
body image disturbances. Most of them conducted on patients with eating disorders, body
dysmorphic disorder, obesity or normal weighted women. Although the effectiveness of CBT
has shown in terms of depression, anxiety or enhancing quality of life in cancer patients, there
is lack of studies that focus on body image changes among cancer patients.
Grant and Cash (1995) modified CBT into a different format as a psychotherapeutic
approach that can be used in treating body image disturbances. It is administered in a group
setting with a therapist or the program can be self maintained by the patient through modest
contact with the therapist. Grant and Cashs (1995) CBT includes 8-step program. It involves:
116 zen nen Sertz
1) Self-assessment of historical, cultural, physical and interpersonal influences in

developing a negative body image
2) Training in self-monitoring (diary keeping) of body image experiences to identify
their antecedent events, mediating cognitions, and emotional and behavioral
consequences
3) Relaxation training (muscle relaxation, diaphragmatic breathing, guided imagery,
and self-instruction) and desensitization with imaginal and mirror body-areas
exposure, and imaginal exposure to precipitating situations and events.
4) Identification and disputation of 10 dysfunctional appearance assumptions.
5) Self-monitoring of 12 cognitive body image errors and cognitive restructuring to
alter faulty internal dialogues.
6) Self-assessment of avoidant and compulsive body image behaviors and the use of
multiple strategies (e.g., exposure, response prevention, stress inoculation, covert
rehearsal, and self regulation) to decrease these maladaptive patterns.
7) Mastery and pleasure and self-affirming exercises to increase adaptive body image
behaviors and experiences.
8) Problem solving, covert rehearsal, and assertion to manage troublesome interpersonal
events and prevent relapse (Cash and Lavallee 1997).
This model can be applied as an adjuvant therapy to drug or non-drug treatments such as
psychotherapies in cancer patients with significant body image disturbances. Because the
evident link between body image and psychological disorders such as disturbed body image
change in depression, selected treatment for depression will also be helpful for body image
disturbance in cancer patients.
In conclusion cancer patients who are experiencing serious emotional problems related to
changes in appearance may benefit from counseling or support groups. Individual
psychotherapy guides people to look at the reasons for focusing on their looks as well as ways
to cope with the changes. Pastoral or spiritual counseling can help remind patients that they
are more than just their bodies. Support groups for cancer patients are good places to share
feelings and useful tips about dress and grooming with others who are in the same situation.
ALTERNATIVE AND COMPLEMENTARY THERAPIES

Alternative and complementary therapies may help patients to deal with changes in self
and body image through developing a fuller self-image, finding new interests, or learning new
skills. Meditation and prayer can help patients put physical appearance inside a larger
framework of values. Yoga, t'ai chi, art, and dance or movement therapies are choices of
exercise for some of cancer patients. Lastly, massage, calming or uplifting music, and
aromatherapy may help patients in balancing the side effects of cancer treatment with
relaxing and pleasant experiences.
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Chapter 6
BEYOND THE MEDIA: A LOOK AT OTHER

SOCIALISATION PROCESSES THAT CONTRIBUTE
TO BODY IMAGE PROBLEMS AND
DYSFUNCTIONAL EATING
Marion Kostanski*
Dept Psychology & Social Sciences
Victoria University, Australia
ABSTRACT
The activities of shopping for clothes and dressing oneself are a major component of
our everyday lives. As noted by Goffman, 1990, a large portion of our social recognition
and engagement centres on the preliminary assessment we make of others presentation
and external cues. Extending on this theory, it is argued that ones experience and beliefs
around the act of dressing, and particularly purchasing clothes, will have a strong
influence on how one feels about, and engages with, their body. Through a series of
interviews and the development of a self report inventory, the current research offers an
evaluation of the impact that these activities have on young womens psychosocial
wellbeing and health. Outcomes of both quantitative and qualitative research indicated
that over 40% of the variance in reported experiences was explained by four primary
factors; social engagement, self identity processes, use of popular media such as fashion
magazines, and emotional affect.
As predicted, shopping for clothes was identified as an important personal and social
activity for many participants. Reliance on popular media for informed choice, updates
on trends and knowing what was important was also strongly endorsed. Of significance
was the prevalence of reported negative affective experiences in relation to the
experience of shopping for clothes. Issues such as depressed mood, feeling frustrated, and
being embarrassed to ask for assistance, were consistently reported to be a consequence
of this activity for the women. A ffect was found to significantly predict over 30% of
the variance in reported body image dissatisfaction in young women.
*
Email: Marion.Kostanski@vu.edu.au
122 Marion Kostanski
The outcomes of this research suggest that there are practical and pragmatic steps
that may alleviate some of the negative experiences. Further the outcomes of this research
confirm that shopping for clothes is imbued with very powerful explicit and implicit
messages that impact strongly on how we feel and perceive ourselves. The underlying
dynamic of this process is a paradoxical dilemma, wherein the women are drawn to
engage in a social process that incorporates both elements of pleasure and necessity and
simultaneously struggle with an internalised attribution style that leaves her with a sense
of being personally responsible for many of the things that go wrong. The research
confirms that there are many extraneous factors that impact on and influence how women
perceive and feel about their body. Research into the development of educational
programmes that empower women in articulating and addressing their experiences of
engaging in their world from a nonself-deficit perspective of faulty attributions is
recommended.
Dressing oneself is a necessity of everyday living. It could be argued that, as with other
social acts, there is a level of choice in this behaviour. However the perceived choice is
ironic, in that choice is about what one wears, not whether one wears clothes. Moreover, this
perceived choice over what one wears is confined to a sardonic conception of choice that is
confined by the parameters of what is offered for one to choose from. The presented research
explored some of the issues associated with dressing oneself, namely shopping for, and
making choices about what clothes to wear. The outcomes of this research indicate that the
process of purchasing clothes and dressing oneself is fraught with inherent contradictions and
strongly reinforces normative values and ideals about the body.
As reported by Fredrickson and colleagues (1988), the conceptual process of trying on a
swimsuit can have a serious impact on a womans sense of wellbeing. Outcomes of their
research have led to the development of the theoretical proposition of self objectification.
From this perspective, the authors propose that in many instances women engage in a process
of splitting and are relegated to becoming an observer of their own body. This observation of
self is accompanied by elevated concerns associated with shame, depression, decreased
performance and restrained eating behaviours. Fredrickson et als research has led to an
extensive array of research that strongly supports the concept of women needing to dissociate
from the subjective in managing their perceptual experiences of their body. Unfortunately,
whilst such research offers a way of coding and categorising womens struggles with identity
formation, we remain none the wiser about what may be done to alleviate the potentiality of
living in a dissociated fragmented state.
In furthering this area of research, Cash and Pruzinsky (2002), proposed that researchers
might turn their attention to everyday appearance management behaviours and acts that
women may have more direct control over. However it seems there remains limited research
into this area. Tiggeman, Verri and Scaravaggi (2005) did evaluate the personal and social
importance of clothing to women across two cultures (i.e. Australian and Italian) and its
relationship with body image. Their study indicated that the personal importance of clothing
was significantly associated with internalisation of body ideals and body dissatisfaction for
both groups of women. However the measure used to evaluate this issue, importance of
clothes, was developed specifically for their study and based on assumed issues of what might
be important for Italian women.
Beyond the Media 123
Recently, the American Psychological Association Task Force (APATF: 2007) noted that
the ongoing process of objectification and disembodiment of the female from herself has
resulted in many socio-cultural practices that serve to perpetuate identified self loathing of her
physical shape and form. The report highlighted how current socio-cultural structures
including television, contemporary magazines, print and other forms of advertising, sports
media, movies, music and products such as cosmetics and clothing all serve to present the
female form as a sexual object, wherein the female becomes disembodied and subject to the
gaze of others. The APATF report outlines many of the implicit assumptions made about
women and particularly young girls in our culture. Further, it highlights how manufacturers
frequently engage in promoting highly inappropriate forms of sexual and physical constraints
on how the female should look, act and be seen.
Given the major impact that body image assessment, self objectification and perceptions
of self has been found on how one defines ones sense of self, one would assume that the act
of having to engage in such an intimate process as procuring clothes and dressing oneself
would be an area of major importance. Theoretically, our relationship to clothes has been
placed in the context of being embedded in the development of our social identity (Goffman,
1990; Muggleton, 2000;) or as a symbolic representation of emotional attachments (Brewis,
Hampton, & Linseed, 1997; Friese, 2001). The seminal work of Goffman (1959, 1990) was
instrumental in allowing us to further understand the issue of identity expression and
communication through other than verbal discourses. For him, the presentation of self via
costume, clothing and body language was as significant as the verbal communication we
utilised. Goffman argued that the non-verbal symbolic presentation of self provided the
perfect opportunity to convey strong explicit and implicit messages to the other regarding our
self. This process also facilitated our own access to infer the other.
Since then an extensive library of literature has reiterated the importance of fashion and
mode of dress in relation to ones career (Rucker, Anderson & Kangas, 1999), identity
(Oliver, 1999) cultural and social connectedness (Feinberg, Mataro & Burroughs, 1992) and
gender and sexuality ( Srkrybalo & Ruble, 1999). A review of this literature assures there is
no denying the important place of clothing in our society. As noted by Keenan (2001), there is
much evidence to support the contention that human beings, without violence to our social
nature much of the time, may be regarded as Cloth-animals, creatures that live, move and
have their being in cloth (pp.42). Though some would argue otherwise, it is undeniable that,
for better or worse our clothes are intrinsic to our sense of self as an individual, a social being
and also a member of our community and society. Given that is the case, it is concerning that
very little research has addressed this issue as an important factor associated with body image
ideals and perceptions, apart from acknowledging that it strongly relates to the woman
engaging in self-objectifying her body.
Centrally, the literature on our relationships to clothes is strongly premised within
evaluations of consumer practices (Colls, 2004; Gregson, Crewe, & Brooks, 2002; Miller,
1998). Not surprisingly, this literature is strongly geared towards exploring factors that may
inhibit or improve consumer participation. It discusses the importance of understanding what
people do when they go shopping, and in particular argues for a closer understanding of links
between emotions and increasing practices of consumption. Again, the majority of this
research focuses on woman as the consummate consumer, eagerly engaging in a practice
motivated by her own innate desires.
The majority of our understanding of consumer behaviour is premised on the theory that
desire and emotions are a biologically given or inherent trait. The inherent concern is that this
research is premised on labelling and dichotomising emotions as good or bad, positive or
negative. Notably, this form of research places the act and experience of shopping as a linear
and re-active engagement by the individual with their environment. The subject becomes
object, furthering the current tendency to objectify and disembody the female as she fits
within the confines of her cultural and social world. From this perspective, the literature
purports that by manipulating particular experiences of the consumer, she will feel uplifted,
engaged and have a positive experience in procuring the product offered. As such, the focus is
on increasing consumption, with little regard for any social or individual impact.
An alternative approach to understanding emotions is to view them as evolving from a
process of reflexivity, wherein the person remains subject and has the capacity for self-
reflection and management of their space. As such the act of shopping and clothing oneself
involves active participation, identification with and management of the process by the
individual. From a social psychological perspective our emotions or feelings are not simply
stored within ourselves. Rather, it is through a process of getting in touch with feeling, and
the act of trying to feel and to manage a situation or experience that results in our
subsequent identification of an emotion. Herein, the individual is considered to be an active
viable participant in their life, capable of managing their emotions rather than merely being
subjected to a series of positive or negative experiences that result in good or bad feelings.
Colls (2004) adopts this assumption of discernment when she argued that women manage the
process of shopping through a process that entails cheating, coping and connecting. She
proposed that women intentionally seek out inconsistency in sizing so that they can be a size
smaller than they really are, use a measuring tape to discern actual sizes before trying on
clothes in order to avoid having to face the prospect of having gained weight, or only connect
with others who reflect their own feelings about body size and clothing practices. As such
movements towards larger size models and big girls are considered marketing options for
engaging specific groups. The premise behind this option to defining the emotional
experiences of shopping for clothes is that women are in the powerful position of being able
to manipulate the act to improve their chances of feeling better about themselves. Again the
assumption within Colls research is premised on there being a linear process of subject to
object, with the subject empowered to fully manipulate the environment of the object, and
little concern for exploring the potentiality of confounding factors.
However, as argued previously (Kostanski, Fisher & Gullone, 2004) the process of body
image development and perception in women is not that simplistic. Body image is not a stable
construct wherein consistent or linear relationships occur between objects. Rather, the
development of body image attitudes and perceptions arise as a result of a multi-dimensional
experience that involves both cognitions and emotions, and incorporates a process of both
evaluation and investment. Therefore the person remains an embodied subject who not only
absorbs information and re-acts, but holds a level of investment in desiring or emulating the
images and behaviours they observe. As an extension of this, it is necessary to consider the
act of purchasing and clothing ones body as a particularly strong interactive process,
incorporating the elements of necessity, need and desire. It is inconceivable that such activity
would not have a major impact on ones sense of identity and in particular their perceptions of
their body. Given this proposal, the current assumptions impugned in the literature in relation
to women and shopping for clothes would seem to be erroneous. That is, the current essay
argues that the process is neither one of a linear relationship open to being directly
manipulated into an experience of achieving good or positive emotions nor an inert act
that is easily manipulated by another to intentionally enhance the desires and consumption
practices of the purchaser.
Given the paucity of research that explores this issue, further research, designed as a two
step process of exploring the phenomenological understanding experiences of young women
in the process of contemplation, purchasing and wearing clothes through a series of semi-
structured interviews, and the development of a self report measure to assess the experience
of shopping for clothes was undertaken.
STUDY ONE: WHAT YOUNG WOMEN SAY ABOUT SHOPPING

FOR CLOTHES
Semi-structured interviews were conducted with a strategically targeted group of 12

young women, (aged 19 24 years), who were selected from a larger screening of young
women in relation to research for a bibliotherapy programme (Kostanski & Grixti, 2007).
These young women were identified as having reported no significant or apparent levels of
psycho-social problems (depression, anxiety, elevated body image dissatisfaction or eating
pathology) and to be within normal weight ranges, based on BMI. The young women were
invited to participate in a series of two semi-structured interviews, with the initial interview
designed to explore their experiences, feelings and attitudes in relation to dressing oneself and
shopping for clothes. The format of using open ended questions to guide and engage the
participants, as recommend by Patton, (2002) and others (e.g. Willig, 2001), was chosen in
order to retain a focus on the topic in question. The 2nd interview was designed as a member
checking process of providing validity and reliability to the interviews by offering the women
their transcripts, and preliminary analysis of the data, for verification.
All of the young women confirmed that clothing oneself was a central element of their
daily lives. The study confirmed how pivotal clothing was to their lives, both socially and
personally. Importantly, the interviews confirmed that the concept of clothing oneself was not
a linear functional process. Rather, this complex process was consumed within a primary
social rubric defined as fashion. Indeed the women all spoke of fashion as a given
construct and concept within our lives, with being constantly aware of it, and needing to
keep up as being uppermost in their minds when asked to about the subject of shopping and
clothing oneself.
Identity and Status
All the women spoke strongly about the importance of fashion in defining self and
others. Social identity and status were strongly associated with their personal attitudes to
shopping and assessment of self and others. For some this meant a heavy reliance on
purchasing name brands and labels. As Sandy explained Yes, very much a label person. I
try not to be, to save money, but I end up being a label person, even on socks. Or Cath who
noted that shed like to be more creative but I dont have a creative bone in my body,
therefore I rely on labels. Others did discuss how they were concerned with being
comfortable, and rejected the idea of just buying a garment because it was a certain brand.
However, beyond this variance in personal choice between labels for any price and comfort,
all of them reported being strongly aware of the importance of design, style and quality in
defining others.
For example, Mary explained ...like different brands of fashion, just say someones
wearing a very expensive dress, or something, a very expensive suit compared to someone
else not wearing that kind of suit. I suppose it might mean, what kind ofstatus, not
statushow high they are in society, you know what I mean? Or Janice who proposed that
clothes can bring on a different attitude. For example, if someone is wearing a suit I think
that person is more classy, sophisticated and well mannered.
While the majority of the women admitted that they often mixed and matched their
clothes, by supplementing expensive outer garments with more cheaper products, for some
this was not an option, even if they had not consciously thought about why not. This was very
clearly explained by Cath, who explained I couldnt shop at Kmart or Target or something. I
dont know if its because of what people would think. Yeah, I dont know
For the majority of these women the overt pressure to purchase and conflicting issue of
exposing body parts and wearing skimpy clothes was also quite problematic and left them
feeling quite uncomfortable about themselves, they might say oh yeah, it looks very very
nice, you have got to buy it but you know in yourself that its too revealing or its too
showing my flab or whatever. It can be very depressing (Cath), and also how they evaluated
others like if you see a chic in a short skirt, you know what I mean, a tight revealing top, she
thinks shes all thatyou know, shes got a bit of personality (Amanda).
Personal Experiences and Affect
Alongside the interpersonal considerations of how clothes may influence ones attitudes,
there was also a very strong indication that the experience of purchasing clothes was
personally quite powerful, and strongly impacted on the individuals perceptions of
themselves. For all of them the experience was a mix of the positive affirming experience of
being transformed. When I bought my first suit I felt like I waswhats the
worddistinguished. Like I had achieved somethingmature. If I wear something
provocative or sexy then I feel that way. I think you become what you wear, not who you
really are.(Karen); and the not so positive, as explained by Anne bit of both. Like I go
shopping in the mood that Im going to find something that looks good on me, so Im in a
good mood. But then if you find something that looks shit on you, well obviously that mood
diminishes, and is replaced by a more negative mood. Alternatively, It feels good when I
actually buy something. It feels great. It blocks out the fact that other things in my life are
crap. It takes my mind off things.., retail therapy. Or as Sandy noted I suppose different
days you think different things. Like sometimes when nothing fits, I think, Oh my gosh, Im
really really fat! And other days you think Oh yeah, Im just normal. Amanda further
explained how the ongoing differences between what was visually appealing and the actual
personal experience of seeing the same garment on oneself was a constant difficulty. Its just
soWhen I see something on someone else that looks really good, I want it. But its usually
on tall slim blonde girls the package. And then I who is short and stocky go and ask
where the bought it from, and it ends up looking shit.
Importantly, all of the women had a lot to say about the difficulties of working through
the processes of selecting clothes, trying them on, and finally purchasing them.
Body Image
The issue of body image perceptions and eating behaviours, especially dieting, was a
constant theme throughout all the interviews. As reported by Jane ..like it makes me even
more depressed about my body shape and my body image or Liz It makes me really
conscious of my eating habits. After shopping, no kidding, I always think Ive got to go to the
gym. It can make me so depressed. Indeed all of the women reported their perceptions of
their body being strongly affected by their shopping experience.
The discussion around this topic was always reverted back to how they conceived
themselves as being the problem. For example, Julia noted when something doesnt fit,
immediately you think theres something wrong with you. You know, it automatically comes to
your mind. Thats just how you feel, cos you cant find something you want to wear,I mean
you get thoughts of, you know, its cos Ive got fat thighs or cos of...you know its what you
think about. In contrast to this dilemma, Mary explained it as like if I get straight leg pants,
Ive got stick legs and to wear something like that you need to wear a tight top and then
youve got boobs and small legs and thats what you notice top heavy.
Only two of the young women indicated that, as proposed by Colls, they had the
prescience to avoid this sort of encounter, by not placing themselves in the situation. Both
Margi and Paula said that they avoided having to confront their own image I dont put
myself in that situation where I could try something on that doesnt look good(M;) But
because I avoid it and maybe thats because of my body image sort of, you know what I
mean But because you avoid them (changing rooms), then you dont have to have that
problem.(P). This also meant that they often avoided shopping and relied on a series of
comfort clothes. Paula explained day to day Im looking for more comfort. In terms of
actual clothes, I guess, something that I feel comfortable in, something that not necessarily
has to look a certain way but I want to feel comfortable in, I want to feel confident in it. And I
want it to dont want it to annoy the crap out of me. These two women also noted how this
avoidance of shopping left them feeling isolated and outside the mainstream. Therefore,
whilst they avoided some agonising in the line of shopping, it was not a satisfactory solution
to their dilemma of having to dress or affirming of their sense of self.
Eating Behaviours
For all of the women the experience of shopping for and trying on clothes often lead to
them reflecting on their eating patterns and behaviours. As Jade explained, its a bit
upsetting, because I think Im going to have to lose weight or something, you know, Im going
to have to push myself to loose weight, eat less, which is a good thing and a bad thing
because you know Im not really that skinny, but Im not overweight, you know, Im in
between, but I would like to loose a bit of weight for that. Which is good though. It makes you
upset because youre not the right weight that theyve got out in the shops, you know, for the
pants that they have. This was a common reflection for all the women, and was often
reported as being reminded that they must go on a diet, or stop eating chocolate, or more
interestingly, the need to exercise more.
Karen noted but Ive been exercising more, and obviously the media, with the young
skinny girls, its obviously influenced me. So thats why I am trying to eat healthier and lose
weight, so I can fit into smaller clothes. Not to be like them, but more so I can feel more
comfortable myself. Similarly Jane explained well, I feel hurt and I feel let down in myself if
Ive been exercising and I dont see the results that I want to see. And usually I walk out of
the store not wanting to try on anymore clothes for that day.
Critical Evaluation
An important aspect of the study outcome was the emergence of a very strong critical
evaluation of many of the pragmatic aspects of shopping for clothing. All of the women were
strongly aggrieved by the perceived lack of consistency in sizing between brands. In one
range of clothes their jacket in the extra small fits me. Like its a perfect fit with not too much
underneath its just a zip up jacket. And then in their other shirts, the large just fits
me.its the same company, the same brand, the same make, and you think, well, how does
that work? (m). An important issue for the women was the lack of reality in what was
available and the assumptions of homogeneity of body shape and size. looking at the clothes
is nice, I like that aspect of it. But when it comes to actually buying something dont enjoy it
cos things look good on the hanger, but thats where they belong. Thats how I feel
anyway.(j).
The women also noted how the lack of appropriate facilities, with dark rooms, poor
lighting, faulty mirrors, and in some instances arrogant and dismissive shop assistants were
all factors that contributed to the experience being less than pleasant. Moreover, they were
concerned that most of the changes to promotion of clothes through revising images of
models to be more rea l in size had only focused on the older lady and been relegated to a
less prestigious category of shopping. As explained by Karen the larger models, nine times
out of ten, when theyre advertised, say in the Kmart catalogues, Target catalogues, theyre
all older women, Theres no-one catering or role modelled for the younger generation.
Overall the study indicated that for these women, the shopping experience was an
interactive and transactional process. Often the women had to balance internal needs and
desires with frequent and seemingly uncontrollable variances in the external environment.
Therefore, whereas they acknowledged that their internal state could predicate how they
experienced the event, a multiplicity of factors (such as sizing, inconsistency in quality,
interpersonal engagement with assistants and others, shaping and style) could very easily
impact on and alter how they felt and perceived their body and eating behaviours. Such
findings support the argument that current beliefs about perceived body image need to
incorporate a more fluid, and possible a state-trait distinction (Cash, 2002).
The finding of these interviews indicate that the participants had all internalised current
modern Western thinking in relation to status and class, resulting in many of them being
dependent on external cues such as labels to guide them in their dress sense, style and
purchases. Notably, the process of engaging in this activity was not innocuous. The act of
shopping, trying on clothes, and deciding on purchases was fraught with emotional overtones
and strongly reverberated with a sense of rationalisation, wherein the participant was both
subject and object. The whole process from conception to completion was embedded with
overtones that reinforce social comparison and potentiality for negative self evaluation. It
reinforced normative ideals of shape and size, and in contrast to Colls proposition of the
woman manipulating her environment, often resulted in the women blaming their self for not
fitting in, or being the right shape, rather than the product being wrong. While the women did
indicate a level of critique that suggested the manufacture and presentation of the clothes, and
the environments in which they shopped could be improved, there was no sense that any of
them felt empowered to do anything pro-actively about changing anything but themselves.
This change was to be achieved either through avoidance, restricted eating, increased exercise
or a combination of both.
STUDY TWO: FACTOR DEVELOPMENT AND ANALYSIS

Before being able to generalise these findings to the broader population, it was necessary
to develop a methodology for evaluating the experiences within a more diverse population of
young women. As such, the findings of study one were used as a basis for the development of
self-report survey. This survey was distributed to young women across the Melbourne
metropolitan through convenience snowball sampling methods, with 600 surveys being
distributed. Data from completed surveys was entered into spss for factor analysis and
confirmation of reliability. The set of statements for the survey, related to how one
experiences the process of shopping for clothes, was derived from the original transcripts.
This was achieved through a process of interview scrutiny and inter-rater agreement by four
trained and experienced social researchers, using a content analysis framework. Overall 52
statements covering all aspects of the process as identified by the women were derived. These
statements were set into a self-report format, using a four point Likert scale ranging from
never to always. Following ethical approval, the survey, which included a demographic
profile asking age, weight, height and body image perceptions (based on the revised figure
rating scale) was distributed to a broad cross section of young adult women across
Melbourne. Of the 600 surveys distributed, a total of 480 surveys were completed. Eighteen
surveys were removed from analysis because they were outside the nominated age ranges(18-
25years), and 11 were removed because the primary information was found to be incomplete.
This resulted in 441 (73.5%) of original surveys to be included in the study.
Principle components analysis resulted in an original matrix of 11 factors with an
eigenvalue >1, explaining over 70% of the variance in reported experiences of shopping.
Kaiser-MeyerOlkin measure of sampling adequacy was reported to be 0.91, and Bartletts test
of sphericity strongly significant (x2 = 9462.39, do= 1275, p = .001).
Varimax rotation with Kaiser Normalisation of these variables further confirmed the
presence of 11 strong factors. Examination of these factors, with a reduction of data based on
a forced four, five and six factor solution (determined from scree plot lineation) and limiting
the component item variance to 0.4 was run, This delineation resulted in the selection of the
four factor solution, obtained in 5 iterations and offering 42% of the explained variance as
being representative of the construct under consideration.
The first factor, identified as personal identity and engagement, offered 23% of explained
variance. This factor included 13 items and covered statements such as I enjoy shopping for
clothes with friends, I like to look fashionable, wearing fashionable clothes makes me feel
confident, I am critical of the way other people dress. Inter- item reliability was found to be
excellent, with a standardised cronbachs alpha set at .88.
The second factor derived from this analysis was identified as social engagement. This
factor explained 9% of the variance in shopping experiences and included 12 items with
statements such as friends think what I wear is important, I would not date someone who did
not dress fashionably, it is important to keep up with trends, you can a person by the way they
dress. Standardised cronbachs alpha for factor 2 was reported to be 0.86.
Factor 3 was identified as affect. This factor included 10 items, with statements such as
when I try on clothes in a shop I feel depressed, I get embarrassed asking for help when I
trying on clothes, trying on new clothes is frustrating, I have trouble buying clothes that fit
properly. Excellent inter-item reliability was noted for this factor with a standardised
cronbachs alpha of 0.86, the items explaining 5% of reported variance in participants
reported experiences of shopping for clothes.
The fourth factor was found to explain 4% of variance in responses and was identified as
importance of media. This factor included 8 items, with statements such as magazines are an
important source of fashion information for me, reading magazines motivates me to diet, I
look at fashion magazines to find out latest trends, I often buy fashion magazines. Inter-item
reliability was reported to be excellent with standardised cronbachs alpha of 0.83.
Pearson correlation between these four factors resulted in a significant high positive
correlation between personal identity and engagement and social engagement (r = 0.71, p
<.01) a significant moderate positive correlation between the three factors of media, personal
identity and engagement and social relationships (r = 0.59, p<.01; r = .56, p<.01 respectively)
and a significant negative correlation between personal identity and engagement and affect (r
= -0.18, p <.01). A further comparison of the correlation of these factors with absolute ratings
of perceived cognitive and affective body image dissatisfaction (as derived from the FRS),
indicated there was a negative, low significant correlation between these two constructs and
personal identity and engagement (r = -0.21, p < .05; r = -0.17, p <.05 respectively) and a
moderate positive correlation between the factor of affect and both perceived cognitive and
affective body image dissatisfaction (r = 0.53, p < .01; r = 0.58, p<.01. There was also a high
significant positive correlation between reported perceived cognitive and affective body
image dissatisfaction (r = 0.91, p <.01). No other significant correlations were noted.
Simple linear regression analyses with perceived body image (cognitive and affective) as
the dependent variables and fashion experience factors as the independent variable, indicated
that the factor of affect significantly explained 30% of the variance in perceived cognitive
and 34% of the variance in perceived affective body image dissatisfaction. (adj r2= 0.29, F =
15.79, p < .01, t = 6.01, p < .001; adj r2 = 0.34, F = 18.91, p < .01, t = 7.07, p < .001
respectively). These regression indicating that the Affect factor associated with experiences of
shopping was a significant and strong predictor of body image dissatisfaction in young
women.
DISCUSSION
The results of this research support the proposal that the experience of having to clothe
oneself and purchase clothes does have a strong significant relationship with ones perception
of their body. This activity was reported to be an interactive and transactional process for the
young women in this research. Predominately, there was an ongoing, fluid interaction of the
woman with the process, from preparation and conceptualising to engaging with and
completing her transactions. There was also a high level of internal dialogue that was often
fraught with ambiguities about the actual process and her perceived self worth in that process.
The women reported having to frequently balance their internal needs and desires with the
ambiguities and realities of their environment.
Importantly they acknowledged that their own internal state could strongly influence their
predilection to subsequent engagement in the process. Therefore the process of shopping was
never expected to be consistent, but heavily dependent on their initial state on that particular
day; with them either starting out being happy and optimistic, desperate and harassed; or
feeling out of sorts and less enthused. Similarly, many of the women acknowledged that there
were days when their bodies felt bloated (often due to the timing of their menstrual cycle),
and this could also impact on how they perceived their bodies at particular times. However,
many also indicated that the process of shopping was not only about the actual purchase of
the clothes, but an important component of the social lives, with outings including catching
up with friends, socialising (having coffee, lunch with friends) and checking out what was
happening. As such there were days when one was compelled to go shopping, because of
social needs apart from purchasing clothes. Concurrently, the women reported that the actual
experience of purchasing clothes was full of uncontrollable vagaries, such as inconsistency in
sizing, quality, variety or infrastructure that strongly negated their own sense of volition and
often resulted in experiences of depression, confusion, frustration and self abuse. These
factors were reported to very quickly and easily upset the womans equilibrium and result in
critical self-evaluation and the development of negative perceptions of their body shape
and/or size. As such suggesting that there was a high level of faulty attribution being involved
in the process.
In confirmation of previous social theories (e.g., Goffman, Fienberg et al., 1992; Rucker
et al, 1999) all the women interviewed spoke of the importance of clothes and fashion when
identifying with others. The quality, cut and style of dress were all reported to be an important
aspect of how others were classified and identified. Adjunct aspects of dress such as
jewellery, shoes, the way one walked and hair style were all used as cues for categorising
people according to status and class. This application of attributes according to dress also
reflected back on how the women themselves presented themselves and were perceived by
others. The factor analysis further confirmed these claims and indicated that they explained
over 33% of the variance in participants reported experiences of shopping for clothes.
Notably, the activity of shopping and purchasing clothes was fraught with anguish and
had a very strong impact on how one subsequently felt and perceived their self and their
body. The comparative aspect of seeing positive images of others that created an image of
desire for the noted garment, or viewing the products on display or in the media then having
to actual face the reality of this in the processes of negotiating size and fit, and then
undressing often in public spaces that were ill equipped to cater for their needs of lighting,
mirrors, or privacy, was identified as a major problematic for all the women. Importantly, the
factor analysis confirmed that negative affect explained a large portion of the overall
shopping experience and also significantly predicted body image dissatisfaction in the young
women.
Interestingly, the women did offer some potential solutions to this affective experience.
They proposed that if manufacturers, designers and retail outlets collectively worked together
in defining size and pattern designs and invested in improving the infrastructure of retail
outlets, much of this risk may be eliminated. However, none of the women indicated any
sense of empowerment to influence these desired changes. The lack of sense of self as subject
with agency was strongly evident. Indeed the research suggests that the covert system of
organisational factors that control this aspect of womens lives seemed to have the opposing
effect of rendering them only as active participants within a very confined level of the overall
process.
The women also endorsed the importance of the media in this activity. They did indicate
some level of critical evaluation in discernment of being manipulated, for example by the
seeming contradiction in promotion of larger women but then this being relegated to a
secondary arena. However this awareness did not provoke dissent or calls for change. Rather
the women seemed to be resigned to knowing these matters but not having any voice in
asking for change. The use of the media, in particular fashion magazines and popular
television were reported as an important adjunct to the whole experience of dressing oneself
and shopping for clothes, with many of the women endorsing the use of the media as an
important source of information.
Previous research has shown that intervention programmes that incorporate aspects of
activism and advocacy in the development of media literacy (i.e., Levine, Piran & Stoddard,
1999) are successful in remediating the impact of this socialisation process on womens
internalisation of messages. The findings of the current research would suggest that this form
of intervention may well be beneficial in facilitating a more balanced and positive experience
in the process of clothing oneself and the act of purchasing clothes.
The outcomes of this study suggest that the actual experiences of dressing oneself,
especially the actual thinking about, engaging in the search and actual process of purchasing,
are quite paradoxical. On the one hand the women suggested that they believed they had some
control and personal power in negotiating and determining the outcomes of their experience.
Alternatively they also indicated a high level of apathy to having volition in relation to many
the identified external factors that they believed inhibit the process, made it difficult or
contributed to a negative experience. Whereas, on reflection, the women were able to
critically evaluate their experiences and identify aspects of the process and how these
impacted on the sense of self identity, worth and body esteem, they did not indicate any active
sense of agency in being able to change or expect any improvement. Indeed, as proposed by
Brunner et al, the fish will be the last to discover water, the majority of women in this
research seemed to have adopted a normative resignation to this major aspect of their life as a
flawed but important component. The imputation of social norms behind their conscious
engagement with everyday leads them to hold a subjective level of investment in desiring or
emulating the images and behaviours they are offered as normative through the popular media
and their environment concomitantly with an internal awareness that this actual investment
was also potentially leading them towards feelings of disappointment, despair and self
disparagement.
CONCLUSION
The outcomes of this research confirm that the whole process of clothing ourselves is
imbued with very powerful explicit and implicit messages that impact strongly on how we
feel and perceive ourselves. There are several layers of engagement involved in the process of
clothing ourselves. These involve a high level of social awareness and engagement, and
incorporate a large portion of our leisure time. Friedricksons notion of disembodiment does
offer a way of conceptualising the immediacy of process in the individuals engagement with
purchasing clothes. However it also implies that the act is static and finite, with the woman
being able to suppress the subject as she becomes dissociated from her body as object. To
date the research does not address the fact that the act of shopping for clothes is a multi-
layered complex personal and social process that can have a very powerful ongoing dynamic
affect on how we feel in relation to our bodies as well as how we perceive and relate to
others. Importantly, the research has revealed that there are some very practical and pragmatic
steps that could be implemented within the process of manufacture and sales that could act as
a means of alleviating some of the negative pressures associated with shopping for clothes
and dressing ourselves. Interestingly these steps were not what is commonly thought to be the
solution, that is making the media more realistic. The women saw the media as an important
source of information for what was currently being touted, and many believed it provided a
preliminary way of making informed choice. Rather the women indicated they wanted some
more pragmatic options such as a standard sizing code, quality assurance (shops holding
adequate size ranges to cater for their clients) and a certain level of comfort (decent lighting,
mirrors etc.) and privacy in making their choices.
The main finding of this study would suggest that one way to improve the relationship of
women to their bodies and their world is to empower the individual to adopt a sense of true
agency. Admittedly, there is much room for further research to be directed towards exploring
this area of research to satisfy empirical requirements. However, it is argued that until we can
develop a process whereby women feel safe to objectify the actual processes and normative
events of daily life such that these become the focus of evaluation and assessment of worth,
rather than turning onto themselves, the internalisation of negative perceptions and affect will
continue. When women can confidently and safely say that the external, the material, is where
the problem lay is when we can we expect to negate the increasing tendency towards self
deprecation and body image dissatisfaction that has become so prevalent in our western
world.
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Chapter 7
ALEXITHYMIA, BODY IMAGE AND

EATING DISORDERS
Domenico De Berardis1,2,*, Viviana Marasco1, Daniela Campanella1,

Nicola Serroni1, Mario Caltabiano1, Luigi Olivieri1, Carla Ranalli1,
Alessandro Carano2, Tiziano Acciavatti2, Giuseppe Di Iorio2,
Marilde Cavuto3, Francesco Saverio Moschetta1 and
Massimo Di Giannantonio2
1
NHS, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment,
Hospital G. M azzini Teramo, Italy
2
Department of Neurosciences and Imaging, Chair of Psychiatry,
University G. dAnnunzio of Chieti, Italy
3
IASM, LAquila, Italy
ABSTRACT
It is widely recognized that the body dissatisfaction and an excessive concern about
body weight and shape are core characteristic of Eating Disorders (EDs) and are used to
determine self-worth. Recently, there was an increased interest about the body image as a
multidimensional issue that involves perceptual, attitudinal and behavioral characteristics.
Many researchers have focused their attention mainly to the perceptual and attitudinal
aspects of body image whereas only few studies have investigated the behavioral
consequences related to a negative body image. Moreover, it is known that alexithymia
may play an important role in EDs: specifically alexithymics patients may show a higher
psychological distress than nonalexithymics and the presence of an alexithymic trait may
be related to a higher severity of EDs themselves. Some core aspects of alexithymic
construct, as a difficulty in distinguishing emotional states from bodily sensations, may
be more characterized in patients with EDs and a possible explanation might be that ED
* Correspondence: Domenico De Berardis, MD, PhD. NHS

Dipartimento di Salute Mentale, Servizio Psichiatrico Diagnosi e Cura,
Ospedale Civile G. Mazzini Teramo, p.zza Italia 1, 64100 Teramo (Italy)
Tel. +39 0861429708 Fax +39 0861429706 E-mail: dodebera@aliceposta.it
136 Domenico De Berardis, Viviana Marasco, Daniela Campanella et al.
patients may appear dramatically and deeply incapable of being in touch with their inner
emotive world. As consequence, these subjects may focus their attention on negative
perceptual aspects of body bypassing emotional experiences. Taken together, these
findings may suggest that alexithymia and body image disturbances may be strongly
correlated in EDs and, therefore, the aim of this paper will be to elucidate these
relationships along with the presentation of a clinical study on 64 patients with a DSM-IV
diagnosis of anorexia nervosa.
INTRODUCTION: THE ALEXITHYMIA CONSTRUCT

Coined by Peter Sifneos, the term alexithymia was introduced to designate a cluster of
cognitive and affective characteristics that were observed among patients with psychosomatic
diseases [1]. The alexithymia construct, formulated from clinical investigations, is
multifaceted and includes four distinct characteristics: (a) difficulty in identifying and
describing feelings, (b) difficulty in distinguishing feelings from the bodily sensations, (c)
diminution of fantasy, and (d) concrete and poorly introspective thinking [2]. Alexithymic
individuals have affective dysregulation, the inability to self soothe and manage emotions
because of a lack of awareness of emotions [3]. Thus, the adaptive informational value of
emotions that is important for emotion regulation, often eludes these individuals. These
cognitive characteristics have been attributed to an impaired capacity to elevate emotions
from a sensorimotor level of experience to a representational level, where they can be used as
signaling responses to internal or external events and modulated by psychological
mechanisms [4].
The alexithymic patients show significantly higher levels of anxiety, depression, and
general psychological distress [5]. Alexithymic individuals are prone to both functional
somatic symptoms and symptoms of emotional turmoil because they are psychologically
poorly equipped [6]. The characteristic attributes of alexithymic behaviour are particularly
evident in social relationships with high emotional relevance. A persistent affect-avoiding
interpersonal behaviour may be maladaptive and can cause disturbances and conflicts in such
important relationships, finally contributing to an increased risk of symptoms such as
depression or anxiety [7].
On the basis of the recent knowledge from neurobiology, Bermond [8] distinguishes two
main forms of alexithymia (Types I and II). Type I alexithymia is characterized by the
absence of the emotional experience and, consequently, by the absence of the cognition
accompanying the emotion. Type II alexithymia is characterized by a selective deficit of
emotional cognition with sparing of emotional experience. In non-clinical samples, the
prevalence of alexithymia ranges from 0% to 28% [9]. An increasing body of research
indicates that alexithymia features exist not only in classic psychosomatic disorders but also
in other severe and chronic somatic diseases and psychiatric disorders such as Eating
Disorders (EDs), Somatoform Disorders, Major Depression and other Axis I disorders [10,
11, 12, 13, 14].
Several researchers have pointed out that alexithymic patients may respond poorly both
to pharmacotherapy and psychotherapy [15, 16]. Moreover, it has been suggested that, among
alexithymics, emotional experiences may not reach full conscious symbolic and verbal
elaboration during psychodynamic psychotherapy [17]. Furthermore, patients with
Alexithymia, Body Image and Eating Disorders 137
alexithymia were described as having little interest in introspective and analytical cognitive
activity: this may prevent alexithymics from gain benefits from psychotherapeutic
interventions that require such activities [18, 19]. It was also reported that the negative
reaction of the therapist to an alexithymic patient might be a mechanism through which
alexithymia negatively affects the outcome of psychotherapy. Under this view,
psychotherapeutic methods, which primarily focus on the verbalization of inner emotional
states are probably not the first choice for alexithymic patients [14].
Subjects with alexithymia could undermine these therapeutic strategies in a formal and
superficial manner, which leads to pseudotherapeutic effects, based in fact on social
desirability [3]. Subjects with alexithymia are not blind to emotional information, but they
probably avoid the processing and expression of their own affective states [20]. This could
suggest, particularly in the beginning of a psychotherapeutic treatment, that one should be
cautious about the demonstrative expression of emotional signals or focusing on emotional
conflicts to ensure the therapeutic attachment of high alexithymic patients [21].
MEASUREMENT OF ALEXITHYMIA
Many of the older studies on alexithymia raised concerns about their scientific validity, as
they were conducted with measures that were shown to lack consistence, reliability and
validity such as the Schalling Sifneos Personality Scale (SSPS) and the MMPI alexithymia
scale [22]. In 1985, the Toronto Alexithymia Scale (TAS-26) [23] was introduced as a
reliable and valid measure of the construct.
After several revisions, the actual 20-item version (TAS-20) was developed and, to date,
it is the most widely used instrument to measure alexithymia [24, 25]. The TAS-20 is a self-
report scale comprised of 20 items that are rated on a five-point Likert scale ranging from 1
(strongly disagree) to 5 (strongly agree); five items are negatively keyed. It requires
respondents to indicate to what extent they agree with each item. Items 4, 5, 10, 18 and 19 in
the TAS-20 are reverse scored. Factor analyses have suggested that TAS-20 consists of three
subfactors: difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF),
and externally oriented thinking (EOT) [21]. The first factor (DIF) consists of seven items
assessing the ability to identify feelings and to distinguish them from the somatic sensations
that accompany emotional arousal (e.g., #2: I have physical sensations that even doctors
don't understand and #6: When I am upset, I don't know if I am sad, frightened, or angry).
Factor 2 (DDF) consists of five items assessing the ability to describe feelings to other people
(e.g., #2: It is difficult for me to find the right words for my feelings and #11: I find it hard
to describe how I feel about people). Factor 3 (EOT) consists of eight items assessing
externally oriented thinking (e.g., #8: I prefer to just let things happen rather than to
understand why they turn out that way and #15: I prefer talking to people about their daily
activities rather than their feelings). Cut-off scores for the TAS-20 were provided by Taylor
et al. [3] and a score 61 is considered to be within the alexithymic range.
However, despite the usefulness of this scale, researchers raised some concerns about
self-report measures of alexithymia, as the TAS-20. It is reasonable to think that some
subjects may be unaware of their difficulties in identifying and describing their feelings,
thereby limiting their capacity to report reliably and accurately such deficits on self-report
measures [26, 27] . Moreover, as reported by Koiman et al., the TAS-20 has been criticized
for not including items that directly assess the reduced fantasy and imaginal thinking facet of
the alexithymia construct [28].
Recently, the authors of TAS-20 have developed the Toronto Structured Interview for
Alexithymia (TSIA) which demonstrated adequate item characteristics, inter-rater, internal,
and retest reliability, and evidence of concurrent and factorial validity, but, to date, results of
its use in clinical researches are limited [29]. The TSIA has a hierarchical factor structure
consisting of two higher-order factors (domain scales), each composed of two lower-order
factors (facet scales). The domain scales are operative thinking related to the lower-order
externally oriented thinking and imaginal processes and affect awareness related to the
lower-order factors difficulty identifying feelings and difficulty describing feelings. As stated
by author themselves, the most important difference between the TSIA and the TAS-20 is the
presence of an imaginal processing scale on the TSIA, that was not retained in the
development of the TAS-20, as there were indications that these items had low corrected
item-total correlations and were associated with social desirability response bias [3].
The most common rating scales employed to measure alexithymia are reported in the
Table 1.
Table 1. Most common rating scales employed to measure alexithymia
SelfRating Scales Diagnostic Projective Q-sort Methodology

Interviews Techniques
Schalling-Sifneos Structured Interview Rorschach California Q-Set
Personality Scales for Alexithymia Alexithymia Scale Alexithymia
(SSPS) (TSAI) (RAS) Prototype (CAQ-AP)
MMPI Alexithymia Diagnostic Criteria for SAT-9 (Archetypal 9

Scale (MMPI-A) Psychosomatic test)
Research (DRPR)
Bermond-Vorst
Alexithymia Beth Israel Hospital
Questionnaire Psychosomatic
(BVAQ) Questionnaire (BIQ)
Toronto Alexithymia Observer Alexthymia

Scale (TAS) Scale (OAS)
TAS-R (TAS- Levels of Emotional

Revised) Awareness Scale
(LEAS) *
TAS-20 (TAS-
Revised)
* The LEAS is often employed to measure alexithymia but it wasnt specifically designed to evaluate
the alexithymic construct.
MAY ALEXITHYMIA PLAY A ROLE IN THE PSYCHOPATHOLOGY OF

EATING DISORDERS?
Concerning EDs, Bruch [30] suggested that the difficulty to distinguish and describe
feelings is one of the main problems in ED patients, related to a sense of general inadequacy
and a lack of control over one's life. Moreover, Bruch [31, 32] proposed that in anorexia
nervosa an approach that helps patients to become aware of and identify inner states,
including emotions, would be useful. It is known that alexithymia may play an important role
in EDs: specifically alexithymics patients may show a higher psychological distress than
nonalexithymics [33] and the presence of an alexithymic trait may be related to a higher
severity of EDs themselves [34, 35]. Furthermore, there are evidences that ED patients are
considerably more alexithymic than apparently healthy controls [36, 37] and some studies
have specified that alexithymia is more related to the psychological characteristics of patients
with EDs than to the eating behavior itself [31, 38, 39]. Following Bruchs suggestions,
Taylor, Bagby, and Parker [3] conceptualized ED as affect regulation disorders. Using the
TAS [21, 22] in its different versions, empirical studies reported alexithymia rates ranging
from 22.9 to 77.1% for patients with anorexia nervosa and from 32.3 to 56% for patients with
bulimia nervosa.
It is reported that emotional expression may be inversely related to body dissatisfaction
[40]. However, concerning non-clinical samples, in an interesting and well conducted study,
Quinton and Wagner [41] found that alexithymia did not predict neither total EAT-26 score,
nor two EDI-2 subscales measuring aspects of eating psychopathology. They concluded that,
although disturbed emotional functioning is a feature of eating disorders, it did not relate
directly to the core psychopathology. Some core aspects of alexithymic construct, as a
difficulty in distinguishing emotional states from bodily sensations, may be more
characterized in patients with EDs and a possible explanation might be that ED patients may
appear dramatically and deeply incapable of being in touch with their inner emotive world
[42]. As consequence, these subjects may focus their attention on negative perceptual aspects
of body bypassing emotional experiences [43]. Taylor et al. [36] stated that in eating disorders
a deficit on the cognitive processing of emotions appears, but not on the operational cognitive
style, suggesting that the lack of close relationships of anorexic patients could be due to
alexithymia. Alexithymia is associated with interpersonal distrust, ineffectiveness, and lack of
interoceptive awareness in ED, but it is not related to drive for thinness and body
dissatisfaction. On the other hand, starvation, hyperactivity, bingeing and vomiting, could be
attempts to regulate distressing and undifferentiated emotional states in these patients [3].
Moreover, there are several reasons to believe that alexithymia construct could play a
major role in the illness course of eating disorders: due to their cognitive limitations in
emotion regulation, alexithymic individuals with eating disorders may resort to maladaptive
self-stimulatory behaviors such as starving, bingeing, or drug misuse to self-regulate
disruptive emotions [44]. Speranza et al. [45] found that one of the facets of the alexithymia
construct, the difficulty in identifying feelings, was a negative prognostic factor for the long-
term outcome of patients with eating disorders. Patients with the greatest difficulties at
identifying emotions at baseline were more often symptomatic at follow-up and showed a less
favorable clinical improvement. Moreover, the relative stability shown alexithymia over time
legitimates its use as a potential prognostic factor in eating disorders.
However, when alexithymia is evaluated in patients with EDs, the concomitant presence
of anxiety and depression should be controlled in order to find an answer to the unsolved
question of alexithymia as a state or a trait in ED. De Groot et al. [35] controlling for
depression, found differences in total TAS-26 and in the factor Difficulty in Identifying
Feelings, when comparing bulimic patients and controls. Sexton et al. [46] also controlled for
depression and used the TAS-26, and they found that the factor Difficulty in Identifying
Feelings was more associated with the clinical state of depression in ED, as already suggested
by Parker et al. [47] and De Groot et al. [35].The factor Difficulty in Expressing Feelings did
not change when there was a decrease of depression in restrictive anorexics, and it was also
associated with personality disorders. They concluded that difficulty in describing feelings
was a trait in these patients, and that difficulty in identifying feelings was a state. Corcos et al.
[48] confirmed that alexithymia had an increased prevalence in eating disorders, but its
occurrence could not be interpreted without taking depression into account. They also
reported that increased rates of alexithymia in anorexic patients, compared to bulimic
patients, seemed to be more closely related to depression than to an increased alexithymic
way of functioning itself.
Jimerson et al. [49], using the TAS-26, and controlling anxiety and depression, compared
controls and bulimics free of major depression and they found differences between both
groups in their difficulty to identify feelings. They suggested that alexithymia, as it is
associated with low self-esteem and insecurity, could be enhancing anxiety and depression in
bulimic patients, and that it might be secondary to concurrent depression in certain patients.
Moreover, Eizaguirre et al. [50] evaluated alexithymia and its relationship with anxiety and
depression in 151 females with an ED (25 with anorexia nervosa, restricting subtype, 44 with
anorexia nervosa, bulimic subtype, 82 with bulimia nervosa and a control group of 43
females). They showed that patients with ED presented higher rates of alexithymia than
controls, but after controlling for anxiety and depression the differences among groups
disappeared. Depression and anxiety predicted and correlated positively with alexithymia.
Therefore they suggested that alexithymia was closely related to anxiety and depression, and
could be considered as a trait or a state in patients with ED.
ALEXITHYMIA AND BODY IMAGE: MAY THE BODY CHECKING BE

THE LINK BETWEEN ALEXITHYMIA AND EATING DISORDERS?
It is widely recognized that the body dissatisfaction and an excessive concern about body
weight and shape are core characteristic of Eating Disorders (ED) and are used to determine
self-worth [51, 52].
Recently, there was an increased interest about the body image as a multidimensional
issue that involves perceptual, attitudinal and behavioral characteristics [53, 54, 55, 56].
Many researchers have focused their attention mainly to the perceptual and attitudinal aspects
of body image whereas only few studies have investigated the behavioral consequences
related to a negative body image [57]. Patients with or at risk of ED often have a negative
perception of several body parts; in some cases, they avoid social situations that may point
out their physical appearance and exert a ritualistic checking on their body weight and shape
[54, 58]. The body checking could be considered somewhat similar to compulsive behaviors;
through this checking patients are often able to avoid the anxiety that derives from negative
concerns about their body weight and shape [59, 52]. Examples of body checking are the
repetitive measure of body weight, the frequent exposures at mirror in order to verify possible
body shape changes, the use of particular clothes that can m easure the fatness or the
thinness, the pinching of several body parts to verify their consistence, the comparison with
other people about the own body weight and shape, the checking to see if thighs rub together
and many more [48, 54]. Examining a sample of 260 candidates (44 men and 216 women) for
gastric bypass surgery at a medical center, Grilo et al. [60] reported that checking and
avoidance behaviors were significantly associated with overevaluation of weight and shape
(most patients in their study reported they always or usually avoided clothing that made
them particularly aware of their body shape). This result was also confirmed in patients with
Binge Eating Disorder [61].
On the other hand, in ED patients, paradoxically, the body checking may reinforce the
body dissatisfaction focusing further attention on concerns related to a negative body image
[62]. Fairburn, Shafran, and Cooper [63] have pointed out the rule of the body control in
the clinical evolution of anorexia. The body control and checking are used to monitor the
body weight and shape changes, but increase the perceived imperfections and may lead to a
higher body weight control. As consequence, a hypervigilant body control preserves the
negative beliefs about presumed abnormal body shape. Moreover, they have hypothesized
that the normal variations of body weight may be directly related to mood swings in ED
patients. Since the body control and checking may play a role in the development and
maintenance of an ED, the evaluation of the body checking behaviors may be useful in
therapeutic programs aimed to help patients with ED [64, 65]. In fact, as clinical observations
indicate that body checking increase both the patient's preoccupation with body shape and
weight and the motivation to maintain dietary restraint, a therapeutic program aimed to
reducing body checking may contribute to reduce body dissatisfaction and, consequently, ED
symptoms [66].
Furthermore, it is reasonable to think that individuals with anorexia nervosa and bulimia
nervosa develop a highly organized cognitive schema concerning body- and weight-related
information [67]. Body checking behaviors, like social scanning, may be both positively and
negatively reinforced and strengthen the concerns about body size and shape as well as food
and eating. Body checking rituals are used to regulate emotions through confirmation or
attenuation of fears (and are therefore negatively reinforced), whereas in many circumstances
the checking behaviors reinforce disordered patterns of behavior when the ritual results in an
unfavorable or negative perception [68]. Analyzing clinical samples, Calugi et al. [69] have
compared the body checking of different diagnostic groups of ED patients and have showed
that bulimia nervosa patients check more than those with anorexia nervosa, while an Eating
Disorder Not Otherwise Specified (EDNOS) group had results that were intermediate
between these two more defined diagnostic groups. More recently, Mountford et al. [] have
showed that patients with anorexia nervosa and binge eating disorder had lower levels of
body checking cognitions and behaviours than patients with bulimia nervosa. Interestingly,
the EDNOS patients had the highest level body checking cognitions and behaviours.
It is widely accepted that alexithymic traits may negatively influence the perception of
own body image with a presence of a body dissatisfaction, even in absence of a clinically
defined ED. Our research group evaluated alexithymia and body image in 64 women with
Premenstrual Dysphoric Disorder (PMDD) testing whether alexithymic traits may influence
severity of PMDD or body distress [70]. We found that alexithymia was associated with more
severe PMDD symptoms and alexithymics exhibited significantly poorer appearance
evaluation and body satisfaction than nonalexithymics.
On the basis of these data, we subsequently aimed to evaluate in a non-clinical sample of
undergraduate women, the relationships between alexithymia, body checking and body
image, identifying predictive factors associated with the possible risk of developing an ED
[71]. To do this, TAS-20, Body Checking Questionnaire (BCQ), Eating Attitudes Test (EAT-
26), Body Shape Questionnaire (BSQ), Interaction Anxiousness Scale (IAS), Rosenberg Self-
Esteem Scale (RSES) and the Beck Depression Inventory (BDI) were administered to 254
undergraduate females. We found that alexithymics had more consistent body checking
behaviors and higher body dissatisfaction than nonalexithymics. In addition, alexithymics
also reported a higher potential risk for ED (higher scores on EAT-26) when compared to
nonalexithymics. Difficulty in identifying and describing feelings subscales of TAS-20,
Overall appearance and Specific Body Parts subscales of BCQ as well as lower self-esteem
was associated with higher ED risk in a linear regression analysis. Thus, a combination of
alexithymia, low self-esteem, body checking behaviors and body dissatisfaction may be a risk
factor for symptoms of ED at least in a non-clinical sample of university women. On the basis
of our results, we hypothesized that the presence of alexithymia could play an indirect role in
pathogenesis and maintenance of abnormal eating behaviors facilitating the presence of
depressive symptoms and lower self-esteem. Depressive symptoms and lower self-esteem
may directly exacerbate abnormal eating behaviors or have repercussions on body checking
and body dissatisfaction with a worsening of abnormal eating behaviors themselves. On its
own, abnormal eating behaviors may worsen self-esteem and body dissatisfaction. In fact, it is
reported that abnormal eating attitudes and lower self-esteem may be linked to higher body-
image dissatisfaction [72, 73, 55].
In addition, difficulty in identifying and describing feelings may let misinterpret
perceptual and behavioral aspects of body image. This may cause a higher body checking
that, on its own, may lower self-esteem and increase negative body-image perception. As
consequence, it can be triggered a vicious circle that may conduct to a higher risk of
developing and maintaining a possible ED. In accordance with Overton et al. [74], we
suggested that women with EDs are proficient at using disordered eating behaviors to
manipulate their experience of both positive and negative emotional states. This dynamic may
be more pervasive especially in the presence of alexithymia and should be recognized as an
important maintenance factor. ED patients under- and/or over-regulate emotions due to an
impaired ability to use blends of emotion to coping with emotional experience [1]. This
hypothesis is consistent with de Groot and Rodin [75] who suggested that individuals with
EDs may either have little access to their emotional life or feel dominated and overwhelmed
by it.
In conclusion, alexithymic individuals may have a more prominent body checking that
generates, on the basis of cognitive biases, a negative body image, thus increasing the risk of
developing an ED [65,76].
Negative body image is an important component of a variety of prevalent health
problems in females such as depression, obesity, and the spectrum of disordered eating [77].
This spectrum encompasses varying combinations and degrees of binge-eating and unhealthy
forms of weight management such as restrictive dieting and self-induced vomiting. At the
extreme end of the spectrum are the well-known syndromes of anorexia nervosa, bulimia
nervosa, and binge-eating disorder.
Stice [78] conducted a meta-analytic review of longitudinal studies examining the ability
of body dissatisfaction ( negative body image) and other hypothesized risk factors to predict
increases in eating pathology. In general, data from these studies confirm that negative body
image is an independent predictor of disordered eating. Overall, Stices (2002) review
supports a model linking pressures to be thin from family, friends, and media to
internalization of the slender beauty ideal and to overvaluation of appearance as a feature of
self-concept. These components set the stage for negative body image, which in turn
increases the probability of four interlocking components of eating pathology: dietary
restraint, binge-eating, body checking and negative affect.
CLINICAL STUDY
The aim of the clinical study was to evaluate relationships between alexithymia, body
checking and body dissatisfaction in a sample of adult patients with Anorexia Nervosa (AN).
1. Methods
1.1. Participants
The participants consisted of 64 women with a diagnosis of AN (mean age 23.9 4.15;
mean BMI 16.1 1.29), each of whom was referred to one of two specialist eating disorder
services. They were recruited at the point of assessment and were diagnosed (using DSM-IV
criteria [79]) by trained clinicians, using a semi-structured interview. Body mass index (BMI)
was recorded for each participant. BMI was calculated by dividing weight in kilograms by
height in meters squared. A BMI below 18.5 indicates unusual thinness. A BMI between 18.6
and 24.9 is considered normal. A BMI over 25 indicates overweight or obese status.
1.2. Measures
1.2.1. Body Checking Questionnaire (BCQ)

The BCQ is a reliable and valid measure of body checking behaviors [54]. It is a 23-item
self-report questionnaire with higher scores associated with more intense body dissatisfaction,
body-image avoidant behaviors, and general eating disturbances. The BCQ measures a high-
order factor (body checking) with three subfactors that are highly correlated: overall
appearance (OA), specific body parts (SBP) and idiosyncratic checking (IC). The Italian
version has been validated by Calugi et al. [66] and confirmatory factor analysis confirmed
the same three-factor structure of the English version. In our study, Cronbach's was 0.92 for
the BCQ total score and 0.88, 0.90, 0.79, respectively, for the OA, SBP and IC subfactors.
1.2.2. Toronto Alexithymia Scale (TAS-20)

Alexithymia was measured using the 20-item TAS-20, the most widely used measure of
alexithymia [3]. The TAS-20 has a three-factor structure [80]. Factor l assesses the capacity to
identify feelings and to distinguish between feelings and the bodily sensations of emotional
arousal (Difficulty in Identifying Feelings, DIF); Factor 2 reflects the inability to
communicate feelings to other people (Difficulty in Describing Feelings, DDF); Factor 3
assesses Externally Oriented Thinking (EOT). Cut-off scores for the TAS-20 are provided by
Bagby et al. [21] and a score of 61 and above is considered to be within the alexithymic
range. The Italian version of the TAS-20 was used [81]. In our study, Cronbach's was 0.85.
1.2.3. Body Shape Questionnaire (BSQ)

The BSQ is a 34-item self-rating scale that estimates the participants' disturbed
perceptions of body size and body shape [82]. Higher scores reflect greater body-image
concerns. The BSQ is a widely used instrument in studies of eating and weight disorders. The
Italian version was used [83]. In our study, Cronbach's was 0.95.
1.2.4. Beck Depression Inventory (BDI)

Depressed mood was assessed with the Italian version of BDI [84], a 21-item self-report
scale with higher scores indicating more depressive symptoms. In our study, Cronbach's
was 0.90.
1.2.5. State-trait Anxiety Inventory (STAI)

Anxiety was assessed with the STAI scale [85] that consists of two 20-item Likert self-
report scales. The State Anxiety Scale consists of items asking individuals to indicate how
they feel at this moment (STAI-S) on a 4-point scale ranging from 1 not at all to 4 very
much so. The Trait Anxiety Scale (STAI-T) consists of items asking individuals to indicate
how they generally feel on a 4-point scale ranging from 1 almost never to 4 almost
always. In our study, Cronbach's was 0.90 for the STAI-S and 0.91 for the STAI-T.
2. Statistical Analysis
Descriptive statistics (means and standard deviations as appropriate) and percentages

were computed for the study sample on demographic variables and all psychometric scales.
The differences between alexithymics and nonalexithymics were tested by using analyses of
covariance (ANCOVA) with TAS-20 positivity/negativity as factor and age, BMI, BDI and
STAI scores as covariates.
A blockwise linear regression analysis was performed in order to find which variables
were associated with body dissatisfaction (BSQ score as dependent variable). In the first
block BMI, demographic variables and measures of psychological distress (such as BDI and
STAI) were entered. In the second block body checking measure (BCQ subscales) was added
to the model. DIF, DDF and EOT subscales of TAS-20 were entered in the last block. The
quality of the regression model was also tested using the DurbinWatson statistic (a value
between 0 and 4 indicating the amount of autocorrelation within the model with an optimum
of 2.0). P values .05 were considered to be statistically significant. All statistical testing was
two-sided. Statistical analyses were performed using SPSS for Windows release 10.0.0
(2000). All data are expressed, if otherwise specified, as mean standard deviation.
3. Results
TAS-20 score was 53.6 11.5. 39.1% (n=25) of 64 subjects scored 61 or more on TAS-
20 total score and therefore were categorized as alexithymics. BDI score was 16.7 9.4. No
differences between groups were found concerning age, marital status and occupation.
The results of ANCOVA controlling for age, BMI, BDI and STAI scores showed that
alexithymics had more consistent body checking behaviors (higher scores on BCQ and
subscales OA, SBP, IC for all measures p<0.001) and higher body dissatisfaction (higher
scores on BSQ, p<0.001) than nonalexithymics. The comparison between alexithymics and
nonalexithymics on BCQ total score controlling for age, BMI, BDI and STAI scores is
depicted in Figure 1.
(*) p<0.001.
Figure 1. Boxplots of comparison of BCQ total scores scores between alexithymics and
nonalexithymics. (ANCOVA with age, BMI, BDI and STAI scores as covariates) The solid line
indicates the mean. The lower and upper boundary of box indicates 25th and 75th percentile,
respectively. The upper and lower error bars define the 10th and 90th percentiles.
A blockwise linear regression analysis with BSQ scores as dependent variable and
potential predictive factors as independent variables was conducted in order to determine the
contributions of the variables for predicting body dissatisfaction in the whole study sample
(Table 2). The results of linear regression indicated that DIF and DDF subscales of TAS-20
were significantly associated with higher body dissatisfaction as well as higher scores on
BCQ-OA and BCQ-IC. In this analysis, the R values demonstrated good accuracy of the
prediction with the model accounting for 78% of the variance in BSQ. In addition, the
Durbin-Watson coefficient was 1.746 (near to the optimum of 2.0) and the standardized
residuals were normally distributed.
Table 2. Blockwise linear regression analysis with BSQ score as dependent variable and
potential predictive factors as independent variables. Only statistically significant
variables are showed
Variables Standardize CI 95%

t p
d (reference)
Constant
1.71/10.60 5.53 <0.001
BCQ Overall appearance
0.43 0.11/0.75 4.95 <0.001
BCQ Idiosyncratic checking 0.36 0.14/0.67 3.31 0.001
TAS-20 DIF
0.35 0.13/0.60 3.23 0.001
TAS-20 DDF
0.21 0.01/0.35 2.12 0.01
4. Discussion
To our knowledge, this is the first study that evaluated interrelationships between
alexithymia, body checking and body image in a sample of women with anorexia nervosa.
Consistent with our hypothesis, alexithymic subjects reported higher body checking behaviors
and body dissatisfaction than nonalexithymics even controlling for age, BMI, depressive
symptoms and anxiety levels. Moreover, the results of linear regression showed that difficulty
in identifying and describing feelings were significantly associated with higher body
dissatisfaction as well as the presence of two components of body checking (Overall
appearance and Idiosyncratic checking).
These results are consistent with those of an our previous study on non clinical sample
[68] and confirm that alexithymia, body checking and body dissatisfaction are closely related
at least in patients with anorexia nervosa. It is important to underline that higher body
checking and body dissatisfaction may be independent by levels of anxiety or by the presence
of depressive symptoms. It is reasonable to hypothesize that the presence of difficulty in
identifying and describing feelings is able per se to exacerbate body checking and
dissatisfaction in a unclear way.
However, not all facets of alexithymia construct may equally contribute to higher body
checking and dissatisfaction. In fact, factor 3 of TAS-20, i.e., EOT, appears to be a quite
independent variable from body checking and dissatisfaction. Externally oriented thinking
corresponds closely to la pensee operatoire a concept launched by French researchers Marty
and de M'Uzan in 1963 [86]. The main characteristics of la pensee operatoire, are a
utilitarian style of thinking and a relative absence of fantasies. It seems that externally
oriented thinking can be described as a personality trait that does not readily change with
mood. In contrast, the other two factors of the TAS-20, i.e., Difficulty in Identifying and
Describing feelings, change with the degree of psychological distress, and thus also reflect
changes in inner states. Concerning EOT another consideration must be done: in the cross
validation of factor structure of Italian TAS-20, coefficients and mean interitem correlation
coefficients indicated optimal levels of item homogeneity for DIF and DDF whereas EOT
coefficients were considerably lower in magnitude (Bressi et al., 1996). Also in other studies,
is reported that the coefficients of EOT factor were lower than those of the DIF and DDF
factors [87].
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Chapter 8
A META-ANALYTIC REVIEW OF SOCIOCULTURAL

INFLUENCES ON MALE BODY IMAGE
Bryan T. Karazsia1* and Kathryn Pieper2

1
Department of Psychology, The College of Wooster, Wooster, OH 44691 USA
2
The Section of Developmental and Behavioral Sciences,
Childrens Mercy Hospitals and Clinics
Kansas City, MO, 64108 USA
ABSTRACT
Male body dissatisfaction is prevalent and associated with maladaptive outcomes.
Discrepancies exist in this literature concerning the importance of sociocultural
influences on mens body dissatisfaction. The present meta-analysis explored the extent
to which these discrepancies may be related to the way in which constructs are assessed.
We hypothesized that studies that assessed muscularity as a component of sociocultural
influences or mens body dissatisfaction would have larger effect sizes than studies that
did not assess muscularity. Results largely supported this hypothesis; the average effect
sizes of the relationship between internalization and awareness of ideal body figures and
mens body image differed as a function of methodology. When muscularity was
assessed, the magnitude of effect sizes was similar to those reported with female samples.
These results have implications for research and interventions with males.
Keywords: body dissatisfaction, sociocultural influences, internalization, meta-analysis.
*
Please address correspondence to:
Bryan T. Karazsia
Department of Psychology
The College of Wooster
Wooster, OH 44691
E-mail: bkarazsia@wooster.edu
Phone: 330-263-2302
Fax: 330-263-2276
154 Bryan T. Karazsia and Kathryn Pieper
INTRODUCTION
Scientific inquiry related to mens body image has gained increased attention during the
past decade (Thompson & Cafri, 2007). Although early reports suggested that men were
largely satisfied with their bodies (e.g., Fallon & Rozin, 1985), more recent research across
multiple cultures revealed that male body dissatisfaction is prevalent (e.g., Chen, Gao, &
Jackson, 2007; Frederick et al., 2007) and associated with risky body change strategies (e.g.,
steroid use, appearance and performance-enhancing supplement use, maladaptive dieting;
Cafri et al., 2005). Empirical evidence also supports relationships among mens body image
and psychological sequelae, including depression and variants of body dysmorphic disorder
(Cafri, Strauss, & Thompson, 2002; McCreary & Sasse, 2000; Ricciardelli, McCabe, Lillis, &
Thomas, 2006). Consistent with decades of research that identified important links between
sociocultural variables and female body image (Cafri, Yamamiya, Brannick, & Thompson,
2005; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999), research with males suggests
that multiple sociocultural variables play important roles in mens experience of body
dissatisfaction (e.g., Chen et al., 2007; van den Berg et al., 2007). However, some
discrepancy exists in the literature regarding the importance of sociocultural variables as
predictors of mens body image, and this discrepancy may be related to the assessment of
constructs in ways that are meaningful for men (Karazsia & Crowther, 2009). The purpose of
the present review was to explore these discrepancies using meta-analytic procedures.
The majority of research on sociocultural influences on female body dissatisfaction
targeted three sociocultural constructs: awareness of a thin ideal, internalization of a thin
ideal, and perceived pressures to conform to the thin ideal (Cafri et al., 2005; Stice, 2002;
Thompson & Stice, 2001). While awareness concerns the extent to which women are aware
of a societal ideal body figure, internalization represents the process of adopting this ideal as a
personal goal and standard (Jones, 2004; Thompson, van den Berg, Roehrig, Guarda, &
Heinberg, 2004). As noted by Cafri and colleagues (2005), the distinction between awareness
and internalization has not always been clear. Thompson and colleagues (2004) conducted a
psychometric evaluation of two common measures of internalization, the Sociocultural
Attitudes Towards Appearance Scale (SATAQ-3; Thompson et al., 2004) and the Ideal Body
Internalization Scale-Revised (IBIS-R; Stice, Ziemba, Margolis, & Flick, 1996), and
concluded that these scales measured different constructs. Specifically, Thompson and
colleagues (2004) contended that the IBIS-R may assess an awareness of sociocultural norms,
as opposed to internalization of these norms. Differences between these constructs can be
illustrated by juxtaposing items from the SATAQ-3 Internalization Scales (e.g., I would like
my body to look like the people who are in the movies.) with items from the original
SATAQ Awareness Scale (e.g., People think that the thinner you are, the better you look in
clothes.) or the IBIS-R (e.g., Slender women are more attractive). Another important
sociocultural variable is ones perceived pressure to conform to the societal ideal (i.e., for
women, perceived pressure to be thin). This construct is typically assessed with either the
Perceived Sociocultural Pressure Scale (Stice, Nemeroff, & Shaw, 1996; sample item: I've
felt pressure from my friends to lose weight) or one of several scales developed by
Thompson and colleagues (e.g., SATAQ-3, Thomson et al., 2004; Multidimensional Media
Influence Scale; Cusumano & Thompson, 2001).
A Meta-Analytic Review of Sociocultural Influences on Male Body Image 155
In a recent quantitative review of sociocultural influences on female body image, Cafri

and colleagues (2005) concluded that all three of these variables had significant relations with
body image, with effect sizes in the medium to large range. Comparisons among the
relationships of each of these three variables and body image revealed that internalization of
and perceived pressures to conform to the thin ideal had stronger associations with body
image than awareness of the thin ideal. As discussed by Cafri and colleagues (2005), these
findings have important implications for clinical interventions because they emphasize the
potential benefit of targeting the extent to which one relates herself to the ideal, as opposed to
only challenging ones cognitions about the ideal (e.g., Stice, Trost, & Chase, 2003).
In recent years, researchers have attempted to extend research concerning the importance
of these three sociocultural influences to male populations. In a meta-analytic review, Barlett,
Vowels, and Saucier (2008) concluded that perceived pressures from media were related with
mens body dissatisfaction, as well as psychological and behavioral outcomes. However,
some discrepancy exists regarding the importance of sociocultural variables as predictors of
mens body dissatisfaction. For example, Karazsia and Crowther (2009) summarized results
of studies that examined the role of internalization as a mediator between social influences
and mens body dissatisfaction. Discrepant findings among the studies were noted, with some
studies documenting significant relations among internalization and male body dissatisfaction
(e.g., Halliwell & Harvey, 2006; Jones, Vigfusdottir, & Lee, 2004; Karazsia & Crowther,
2008) and other studies reporting no significant relations between these constructs (Bearman
et al., 2006; Chen et al., 2007).
One potential explanation of these discrepant findings concerns the extent to which
constructs were assessed in ways that were meaningful for men (Karazsia & Crowther, 2009).
This contention is supported by recent research that elucidated important differences in the
phenomena of body dissatisfaction across males and females. While a central component of
body dissatisfaction among females is thinness, most men are more focused on an ideal that is
growing increasingly muscular (e.g., Leit, Pope, & Gray, 2001; McCreary, 2007). Indeed,
several studies documented greater self-ideal discrepancies among men when target figures
varied with respect to muscularity versus body fat (Olivardia, Pope, Borowiecki, & Cohane,
2004; Pope et al., 2000). Further, the limited psychometric research that examined identical
scales and item content across sex suggests that assessment measures may operate differently
for men and women (McCreary, Sasse, Saucier, & Dorsch, 2004). Therefore, it seems
reasonable to speculate that discrepancies in previous research regarding the importance of
sociocultural influences (i.e., internalization, awareness, and pressures) on mens experience
of body dissatisfaction may be confounded by the methodologies employed in these studies.
This issue was explored in the present meta-analytic review of sociocultural influences on
mens body image. In many respects, the present methodology was based on the
aforementioned meta-analysis by Cafri and colleagues (2005). However, in their review,
only data on female participants were included because methods of assessing male-
appropriate sociocultural influence and body imagehave not been widely used (p. 424).
Indeed, some research on body image among males continues to rely on instruments that may
be more relevant for females, despite overwhelming evidence that a key component of male
body dissatisfaction is muscularity (Karazsia & Crowther, 2009). Even so, we believe there
are several reasons that a quantitative review of sociocultural influences on male body
dissatisfaction is warranted: a) the body of research that examines sociocultural influences on
male body image is growing, b) discrepant findings within this body of literature exist, and c)
these discrepancies may be related to methodological aspects of the studies. One of the
benefits of meta-analysis is that the quantitative summary of numerous single studies leads to
correct conclusions and hence leads to cumulative knowledge (Schmidt, 1996, p. 119), and
therefore, this methodology is appropriate for exploring the aforementioned discrepancies.
A primary goal of this review was to consider the extent to which methodological
confounds may explain discrepant findings in the literature. Consistent with this goal, we
coded studies based on the item content of measures that were included. Based on previous
research that demonstrated the saliency of muscularity with respect to mens body
dissatisfaction (e.g., McCreary, 2007), we hypothesized that studies that included muscularity
as a component of sociocultural influences or mens body dissatisfaction would have larger
effect sizes than studies that relied on measures that did not include a muscularity component.
Stated differently, we examined methodology as a potential moderator of the relationship
between sociocultural variables (i.e., internalization, awareness, and pressures to conform to
an ideal body) and mens body dissatisfaction. Consistent with the original analyses by Cafri
and colleagues (2005), we also compared strengths of relationships between the three
sociocultural variables and mens body image. Although Cafri and colleagues (2005)
documented differences in the strengths of relationships across these variables among
females, no specific hypotheses were made in this regard, as this study represents the first
effort to make such comparisons for male populations.
METHOD
The methods of multiple aspects of this study, including selection of studies,
inclusion/exclusion criteria, and data analysis were based on the original review conducted by
Cafri and colleagues (2005) that targeted women.
Selection of Studies
Following procedures utilized by Cafri and colleagues (2005), we located studies for this
review using four procedures. A computer-based search on PsychInfo and Medline was
conducted with the following keywords: internalization, media, sociocultural, SATAQ, body
image, body dissatisfaction, body image disturbances, IBSS, MMIS, awareness, pressures,
and muscle dysmorphia. We then perused tables of contents of journals that tend to publish
papers in this area of research: Body Image: An International Journal of Research,
International Journal of Eating Disorders, and Psychology of Men and Masculinity. Third,
reference sections of relevant articles were scanned, and fourth, we requested copies of
unpublished data from well-known researchers in this field.
Inclusion/Exclusion Criteria
Studies that assessed one of the three sociocultural variables discussed previously
(internalization, awareness, or perceived pressures) and mens body image were included,
provided that the following criteria were met. Scales for any construct needed to contain at
least 3 items with an estimate of internal consistency greater than .70 (Nunnally, 1978).
Cross-sectional correlation coefficients had to be reported in a study for male samples only.
We limited our analyses to cross-sectional correlations for several reasons: 1) this decision
was consistent with Cafri and colleagues (2005), and 2) very few studies that included men
were longitudinal in nature. When cross-sectional correlations were not reported in a study
that contained relevant constructs, they were requested from corresponding authors.
Consistent with Cafri and colleagues (2005) and to ensure independence, we included only
findings of one article when multiple reports existed based on the same sample. Further, only
one effect size between two particular constructs was included from any single study.
In accordance with criteria described in Cafri and colleagues (2005), papers conducted in
any country were included, although the reports had to be published in English. There was no
age restriction. Studies based on specialized samples (e.g., patients with eating disorders,
body-builders) were excluded due to the possibility of restricted range. Using these criteria,
we identified 27 studies, with a total of 20 effect sizes for internalization and body image, 6
for awareness and body image, and 11 for perceived pressures and body image (see Table 1).
Mean participant ages in these studies ranged from to 8.80 to 25.94. Ethnic composition of
each sample is described in Table 1.
Coding Strategies
A coding sheet was developed for this study to standardize the coding process, and it is
available from the first author upon request. Relevant information from studies was collected,
including sample sizes, demographic information, and effect sizes. The methods of
assessment of sociocultural influences and body image were examined with respect to
whether or not they met aforementioned inclusion criteria. Further, measures were coded with
respect to the content of items on each scale. Specifically, scales were categorized into one of
the following groups: a) item content focuses on thinness/adiposity, b) item content focuses
on muscularity, c) item content focuses on thinness and muscularity, and d) item content
concerns general body satisfaction (i.e., no focus on thinness or muscularity). Scales that
contained general content items as well as either thinness or muscularity specific items were
coded as being thinness or muscularity specific, respectively.
Prior to conducting data analyses, these four groups were used to create three subgroups
that considered the relationships among a sociocultural variable and body image. Specifically,
correlations among constructs were categorized into one of the following three groups: 1)
both constructs included a muscularity component, 2) only one of the constructs included a
muscularity component, and 3) no assessment of muscularity on either construct.
The primary author coded all studies. The second author coded 12 studies independently
for the purpose of inter-coder reliability, which was assessed with intraclass correlations of
measures of effect sizes, sample sizes, and coding of methodology. Inter-coder reliabilities
were very high between the coders (all intraclass correlations > .90). Any discrepancies were
resolved through discussion.
Table 1. Demographic Characteristics, Coding, and Correlations Reported in Studies included in Analyses
Citation N M age Ethnicity (%) Country IV Measure DV Measure

Cafri et al. (2006) 269 14.64 C = 72; AA = 4.5; H = 14; USA MISA-B DMS-Bod
O = 9.4
Cahill & Mussap (2007) 93 22.34 Not reported AUS SATAQ-3-I EDI-2-body
dissatisfaction
Cashel et al. (2003) 138 21.67 C = 59.4; AA = 14.5; H = 3.6; O = USA SATAQ-I EDI-2-body
22.5 dissatisfaction
Chen et al. (2007) 493 16.68 Han = 100% CN IBIS-R NPS-F
PSPS NPS-F
Cusumano & Thompson (2001) 75 10.25 C = 69; AA = 18; USA MMIS-I EDI-body
O = 12 MMIS-P dissatisfaction
EDI-body
dissatisfaction
Giles & Close (2008) 161 22.17 Not reported USA SATAQ-Im DMS-Bod
SATAQ-Am DMS-Bod
Grammas & Schwartz (2009) 202 22.08 A = 37.3; C = 27.7; USA SATAQ-Im MBAS-M
H = 14.5; AA = 13.6
Halliwell & Harvey (2006) 257 Not reported C = 85% UK SATAQ-I MBSRQ-BASS
PSPS MBSRQ-BASS
Harrison, K. (2009) 335 8.80 AA = 53.1; C = 36.8; H = 3.9; O = USA MMIS-I CFS
6.2
Humphreys & Paxton (2004) 100 15.60 Aus/NZ = 77; AUS SATAQ-Im BIBCI-body
Eur = 14; A = 7 dissatisfaction
Jackson & Chen (2008a) 217 15.25 Han = 82.8; O = 17.2 CN IBIS-R NPS-F
PSPS NPS-F
Jackson & Chen (2008b) 219 20.26 Not reported CN PSPS NPS-F
Jones (2004) 139 12.50 C = 68; A = 19; USA SATAQ-Im EDI-body
AA = 2; H = 3 dissatisfactionm
Table 1. (Continued)
Citation N M age Ethnicity (%) Country IV Measure DV Measure

Jones & Crawford (2006) 200 Not reported C = 68, A = 19; H = 3; AA = 1 USA PAP EDI-body
dissatisfactionm
Jones et al. (2004) 346 Not reported C = 71; A = 15; H = 4; AA = 2 USA SATAQ-Im EDI-body
dissatisfactionm
Karazsia & Crowther (2008) 210 19.60 C = 88.6; AA = 6.7; USA SATAQ-3-I DMS-Bod
O = 4.7 SATAQ-3-P
Karazsia & Crowther (2009) 204 19.37 C = 79.4; AA = 13.7; O = 6.9 USA SATAQ-3-I DMS-Bod
Knauss et al. (2007) 819 14.90 Not reported CH SATAQ-3-I NBES/FBCS
SATAQ-3-P
Morry & Staska (2001) 61 19.80 NR CAN SATAQ-Im BSQm
Murnen et al. (2003a) 58 Not reported C = 95 USA SATAQ-Im BES-Bod
SATAQ-Am BES-Bod
Murnen et al. (2003b) 72 Not reported Not reported USA SATAQ-Im BES-Bod
(predominantly C)
Mussap (2006) 120 25.94 Not reported AUS SATAQ-3-I EDI-2-body
dissatisfactionm
Peterson et al. (2007) 142 16.53 C = 94; AA = 3; O = 3 USA SATAQ-P EDI-2-body
dissatisfaction
Phares et al. (2004) 64 9.31 Not reported USA IPIEC EDI-C-DFT
(predominantly C)
Presnell et al. (2004) 238 Not reported Not reported USA IBIS-R BES
(predominantly C) PSPS BES
Smolak et al. (2001) 159 Not reported Not reported USA SATAQ-Im BES-Bod
(predominantly C) SATAQ-Am BES-Bod
Tylka et al. (2005) 241 18.9 C = 80.9; A = 7.1; AA = 6.6; USA SATAQ-Im MBAS-M
H = 4.1; O = 1.2 PSPSm
= Male/Females combined; Ethnicity: A = Asian, AA = African American, C = Caucasian, H = Hispanic, O = Other.

Independent measure: IBIS-R = Ideal-Body Internalization Scale Revised; Inventory of Peer Influence on eating Concerns;
MISA-B = Media Influence Scale for Adolescents Boys; MMIS-I = Multidimensional Media Influence Scale Internalization;
MMIS-P = MMIS-Pressure; PAP = Peer Appearance Pressure; PSPS = Perceived Sociocultural Pressures Scale; PSPSm = PSPS muscularity version; SATAQ-I = Sociocultural Attitudes
Toward Appearance Questionnaire Internalization; SATAQ-Im = SATAQ Internalization male version; SATAQ-Am = SATAQ Internalization male version; SATAQ-3-I =
SATAQ-3 Internalization;
SATAQ-3-P = SATAQ-3 Pressure; Dependent measure: BES-Bod = Body Esteem Scale weight/shape score; BIBCI-body dissatisfaction = Body Image and Body Change Inventory
Body Dissatisfaction; BSQm = Body Shape Questionnaire modified for men;
CFS = Childrens figure ratings; DMS-Bod = Drive for Muscularity Scale Body Image; EDI-body dissatisfaction = Eating Disorders Inventory Body Dissatisfaction; EDI-body
dissatisfactionm = Eating Disorders Inventory Body Dissatisfaction modified for men; EDI-2-body dissatisfaction = Eating Disorders Inventory Second Version Body
Dissatisfaction; EDI-C-DFT = Eating Disorders Inventory Childrens Version Drive for Thinness; MBAS = Male Body Attitudes Scale Muscularity; NBES/FBCS = Body
Dissatisfaction composite of Negative Body Evaluation Scale from Body Image Questionnaire and Frankfurter Body Concept Scale; NPS-F = Negative Physical Self Scale Fatness
Scale.
RESULTS
Following recommendations by Lipsey and Wilson (2001) and procedures utilized by
Cafri and colleagues (2005), all correlations were transformed using a Fishers r to z
transformation, and a weighted average effect size was calculated using inverse variance
weights. A random-effects model was utilized to calculate mean effect sizes and associated
confidence intervals. To simplify presentation and interpretation, we transformed all
cumulative effect sizes to correlation coefficients using a z to r transformation.
Differences Across Methodology Groups
After performing these transformations, we conducted a homogeneity analysis to test the

assumption that all effect sizes for each of the three constructs are estimating the same
population mean. For all three constructs, results were significant (Internalization: Q (19) =
89.09, p < .001; Awareness: Q (5) = 32.99, p < .001; Pressures: Q (10) = 29.15, p < .01),
suggesting that a single mean effect size is not a valid descriptor of the distribution of effect
sizes. This result is consistent with our contention that previous studies were marked by
discrepant findings. Therefore, we proceeded to test Hypothesis 1 (i.e., that methodology
explains the variability among effect sizes) using procedures outlined by Lipsey and Wilson
(2001) and that are analogous to a one-way ANOVA. Specifically, weighted effect sizes,
standard errors, and confidence intervals were computed for each of the three coding groups
within each construct. It should be noted that the tests for homogeneity within these coding
groups were also significant, so effect sizes were computed using a random-effects model
(See Figures 2 through 4). Results are described with respect to each construct.
Internalization
A summary of correlations between internalization and mens body image can be viewed
in Table 2, and the inverse variance weighted mean effect size is displayed for each coding
group. Group coding is a categorical variable, so differences between groups were examined
with the analog to the one-way ANOVA (Lipsey & Wilson, 2001). Results revealed
statistically significant within group variability, QW (17) = 46.66, p < .001, and between
group differences, QB (2) = 42.44, p < .001. The significant within-group test suggests that a
random-effects model is appropriate, while the between-group results suggests that there are
differences among the three coding groups. The differences between group 1 (muscularity
assessed on both constructs) and group 2 (muscularity assessed on one construct) were non-
significant, z = .75, p = ns. The effects sizes of groups 1 (z = 5.38, p < .001) and 2 (z = 4.45, p
< .001) were significantly greater than the effect size of group 3 (no assessment of
muscularity). As can be seen in Table 2, summary correlations for all three groups were
greater than zero (i.e., the lower bound of confidence intervals were all greater than zero).
Table 2. Dot plot of internalization-body image relationships
Study Lower r Upper

Group 1 .37 .41 .44 0 [---*---]
Jones et al. (2004) .18 .29 .38 0 [--------*--------]
Jones (2004) .13 .30 .44 0 [------------*-------------]
Grammas & Schwartz (2009) .17 .30 .43 0 [----------*-----------]
Karazsia & Crowther (2009) .18 .32 .43 0 [------------*---------]
Mussap (2006) .23 .42 .54 0 [----------------*-----------]
Morry & Staska (2001) .17 .43 .60 0 [----------------------*----------------]
Tylka et al. (2005) Study 2 .30 .44 .51 0 [------------*------]
Cafri et al. (2006) .33 .46 .52 0 [----------*-----]
Karazsia & Crowther (2008) .34 .49 .56 0 [------------*------]
Giles & Close (2008) .37 .54 .60 0 [--------------*------]
Group 2 .32 .37 .42 0 [---*---]
Smolak et al. (2001) .03 .19 .33 0 [-------------*-------------]
Humphreys & Paxton (2004) .17 .37 .51 0 [-----------------*------------]
Knauss et al. (2007) .30 .38 .42 0 [-------*---]
Murnen et al. (2003b) .19 .43 .58 0 [-------------------*-------------]
Murnen et al. (2003a) .19 .46 .62 0 [----------------------*--------------]
Cahill & Mussap (2007) .27 .48 .60 0 [----------------*------------]
Group 3 .08 .15 .21 0 [-----*----]
Harrison (2009) -.13 -.02 .09 [----- *0---------]
Cusumano & Thompson (2001) .01 .24 .44 0[--------------------*------------------]
Halliwell & Harvey (2006) .14 .26 .37 0 [---------*---------]
Cashel et al. (2003) .12 .29 .43 0 [------------*-------------]
0 .10 .20 .30 .40 .50 .60
Note. Group 1 = both constructs assessed muscularity; Group 2 = one construct assessed muscularity and one construct assessed a general body component;
Group 3 = no assessment of muscularity on either construct.
Table 3. Dot plot of awareness-body image relationships
Study Lower r Upper

Group 1 .33 .45 .55 0 [---------*--------]
Murnen et al. (2003a) .11 .38 .57 0 [--------------------*------------------]
Giles & Close (2008) .30 .47 .56 0 [---------------*-------]
Group 3 .00 .07 .13 0[----*----]
Presnell et al. (2004) -.11 .02 .15 [------------0*-----------]
Chen et al. (2007) -.03 .06 .15 [------*-------]
Jackson & Chen (2008a) .00 .12 .24 0[--------*---------]
Smolak et al. (2001) -.11 .05 .20 [----------------*------------]
-.10 0 .10 .20 .30 .40 .50 .60
Note. Group 1 = muscularity included on at least one construct; Group 3 = no assessment of muscularity on either construct.
Table 4. Dot plot of pressures-body image relationships
Study Lower r Upper

Group 1 .17 .26 .35 0 [-------*-------]
Jones & Crawford (2006) .09 .23 .35 0 [------------*----------]
Karazsia & Crowther (2008) .15 .29 .40 0 [----------*---------]
Group 3 .33 .36 .40 0 [--*---]
Presnell et al. (2004) .07 .20 .32 0 [----------*----------]
Peterson et al. (2007) .05 .22 .37 0 [---------------*-------------]
Jackson & Chen (2008a) .13 .26 .37 0 [-----------*---------]
Cusumano & Thompson (2001) .05 .28 .47 0 [--------------------*-----------------]
Halliwell & Harvey (2006) .19 .32 .42 0 [------------*--------]
Phares et al. (2004) .07 .32 .52 0 [-----------------------*-----------------]
Knauss et al. (2007) .36 .41 .46 0 [----*----]
Chen et al. (2007) .33 .43 .48 0 [-------*----]
Jackson & Chen (2008b) .32 .47 .54 0 [-----------*------]
0 .10 .20 .30 .40 .50 .60 .70
Note. Group 1 = muscularity included on at least one construct; Group 3 = no assessment of muscularity on either construct.
Awareness
Table 3 contains the summary of correlations with confidence intervals for awareness and
mens body image. As can be seen Table 3, we collapsed correlations across groups 1 and 2.
This decision was made for two reasons: 1) there were no differences between these groups
on correlations between internalization and body image, and 2) there was a very small sample
size of correlations within these groups. For the awareness-body image correlations, the
within group statistic was non-significant, QW (3) = 1.84, p < ns, while the between group
result indicated statistically significant differences between groups 1 and 3, QB (1) = 31.15, p
< .001. As illustrated in Table 3, the effect sizes of studies in group 1 were significantly
greater than effect sizes in group 3. Only the confidence interval of the weighted mean effect
size of group 1 did not contain zero.
Pressures
The summary of effect sizes and confidence intervals of relations between perceived
pressures and body image are displayed in Table 4. Once again, we collapsed correlations
across groups 1 and 2 for the same reasons mentioned above. Results indicated statistically
significant within group variability, QW (8) = 28.71, p < .001. Between group differences
were non-significant, QB (1) = .44, p = ns. Summary correlations for both groups were
statistically greater than zero, as indicated by the lower-bound of the weighted mean effect
sizes being greater than zero.
Differences between Internalization, Awareness and Pressures
Consistent with Cafri and colleagues (2005), we conducted significance tests for the
difference between dependent correlations to explore whether there were differences between
average correlations for internalization and body image, awareness and body image, and
pressures and body image.1 For consistency in comparisons among these three constructs, we
only considered studies that included some assessment of muscularity (i.e., groups 1 and 2) to
examine correlations across constructs. Because some studies assessed multiple constructs,
the comparisons across each construct are not independent. The correlation for
internalization-body image (average r = .41) did not differ significantly from the correlation
between awareness-body image (average r = .45), t(216) = .71, p = ns, although the
internalization-body image correlation was greater than the pressures-body image correlation
(average r = .26), t(1034) = 5.68, p < .001.
Using the inclusion/exclusion criteria for this meta-analysis, there were no studies that
included measures of perceived pressures and awareness. Therefore, the comparison between
the awareness-body image correlation and the perceived pressure-body image correlation is
independent. The average correlation for awareness-body image was significantly greater
than the average correlation for perceived pressures-body image, z = 2.49, p < .05.
CONCLUSION
The primary goals of this review were two-fold: 1) to explore the possibility that
discrepancies in previous research regarding the relationship between sociocultural variables
and male body image can be explained by methodological confounds, and 2) to compare the
relative magnitude of correlations between three sociocultural influences (internalization,
awareness, and perceived pressures) and mens body image. Results from this meta-analysis
revealed that the average correlations for the relationship between two sociocultural
influences (internalization and awareness) and mens body image differed as a function of
item content of measures. Specifically, correlations obtained when item content included a
focus on muscularity were larger than correlations that did not include muscularity as a
component of relevant constructs. Concerning the relative influence of the three sociocultural
influences, results indicated that correlations between mens body image and two constructs,
awareness of and internalization of an ideal body figure, did not differ statistically. Both of
these correlations were statistically larger that the correlation between mens body image and
perceived pressures.
When muscularity was included in assessments, average associations between
sociocultural influences and mens body image were in the medium to large range, according
to Cohens conventions (Cohen, 1988). Generally, the magnitude of these correlations was
similar to those reported with female samples (Cafri et al., 2005). Therefore, sociocultural
influences appear to be constructs that have important clinical significance for preventing or
alleviating body image concerns among men. Interestingly, internalization and awareness had
larger associations with body image than perceived pressures in the present meta-analysis,
whereas internalization and perceived pressures had larger correlations among females (Cafri
et al., 2005). This finding might suggest that mens awareness and internalization of muscular
ideals are more salient constructs with respect to the development of male body
dissatisfaction. However, previous research has indicated that males may actually experience
more pressure in social contexts to change their body than their female counterparts (Jones &
Crawford, 2006), and perceived pressures are associated with mens self-reported body
change behaviors (e.g., Karazsia & Crowther, 2008). Of course, this result should be
interpreted with caution because we found only 2 studies that examined the relationship
between perceived pressures and body image among men included muscularity as a
component of the constructs. Therefore additional research is needed to replicate these
findings and to explore possible explanations.
An additional important finding emerged from this study. Although statistically
differences between correlations that included muscularity as a component and those that did
not, the average correlations between two of the sociocultural influences (internalization and
perceived pressures) and body image were statistically greater than zero, even when the
constructs did not include an emphasis on muscularity. Unfortunately, small sample sizes of
studies prohibited us from differentiating further between studies that focused solely on
thinness versus those that assessed general body dissatisfaction. Even so, this finding is
consistent with recent conceptualizations that male body image may be comprised of at least
two components: a desire for large muscles and a low body fat (Bergeron & Tylka, 2007;
Jones, Bain, & King, 2005).2 Therefore, it is recommended that future research that examines
influences on mens body image considers mens body image as a multidimensional

construct.
Related to this issue, Thompson (2004) expressed concern that there may be an
imbalance between theoretical conceptualization by researchers versus limited attention given
to issues of assessment. More specifically, Thompson (2004) argued that A laudable
empirical question, sound methodological design, and sophisticated data analysis will not
make up for a faulty selection of a measurement tool or misinterpretation of the construct
indexed by a particular measure (p. 7). The present findings echo these sentiments. Measures
of male body image with acceptable to strong psychometric properties are becoming
increasingly available (e.g., Cafri & Thompson, 2004), and measures of sociocultural
influences are being adapted and examined with male populations (e.g., Cusumano &
Thompson, 2001; Smolak et al., 2001). Additional research that elucidates causal pathways
among sociocultural influences and mens body image is needed, and we encourage
researchers to assess these constructs in ways that are reliable and valid for men.
The present meta-analysis was limited in that it did not consider age, ethnicity, or
sexuality of participants. Sample size was too small to examine age and ethnicity as
additional moderators, and sexuality was not assessed in the majority of studies included.
Considersation of these variables will be important for future empirical research and
quantitative reviews. Event so, the present findings have important implications for
interventions or prevention efforts that target male populations. This quantitative summary of
previous research reiterates the important roles of sociocultural influences on mens body
dissatisfaction. These findings are consistent with the notion that ones experience of body
dissatisfaction is a product of interactions among biological, social, and psychological
variables (Ricciardelli, McCabe, Holt, & Finemore (2003). Therefore, it may be important for
interventions to target mens conceptualization of ideal figures, the extent to which men
identify with these ideals, and the way in which men perceive pressures to conform to this
ideal.
ACKNOWLEDGMENTS
The authors would like to thank several researchers who shared data from previously
published or unpublished studies for our review, including Hong Chen, Ph.D., Rick Grieve,
Ph.D., Thomas Hildebrandt, Psy.D., Marita McCabe, Ph.D., Peter Muris, Ph.D., Sarah
Murnen, Ph.D., Katherine Presnell, Ph.D., and Marika Tiggemann, Ph.D.
NOTES
As noted by Cafri and colleagues (2005), it was necessary to include the correlation
among sociocultural variables to examine differences between two dependent correlations.
However, not all studies assessed all of the constructs, so correlations between any two
sociocultural variables were not always available. Following procedures utilized by Cafri and
colleagues (2005), all available data were collected from the studies and averaged. The
average correlations and associated sample sizes were used in the equation for computing the
difference between dependent correlations.
Tylka and colleages (2005) suggested that male body image concerns may contain three
dimensions: muscularity, low body fat, and height. However, in their analyses, mens
concerns about height were not associated with measures of internalization or perceived
pressures.
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Chapter 9
TOUCH AND BODY: A ROLE FOR THE

SOMATOSENSORY CORTEX IN ESTABLISHING AN
EARLY FORM OF IDENTITY (REVIEW ARTICLE)
Michael Schaefer*
Department of Neurology, Otto-von-Guericke University Magdeburg,
39120 Magdeburg, Germany
ABSTRACT
A major cortical representation of our body can be found in the primary
somatosensory cortex (SI). While classic studies understand the body map representation
in SI as fix and reflecting the physical location of peripheral stimulation in the form of
the famous somatosensory homunculus, recent studies challenge this view and suggest a
more complex role for SI. For example, experiments using simple visuo-tactile illusions
demonstrate that SI reflects the perceived rather than the physical location of peripheral
stimulation. Moreover, it has been suggested that SI represents an early concept of our
body that may also include important dimensions of our self. This review reports results
of recent experiments that provide support for this view. For example, SI seems to
respond differentially when observed touch is attributed to the own body compared to
another body (in both cases in absence of any real touch!). Further experiments on
observing touch on others body report that activity in the somatosensory cortex is
closely associated with the personal trait of empathy. Hence, it is proposed that the
somatosensory cortices may be involved in social perception processes and thereby
establish first forms of a unique body image and a personal identity.
* *Correspondence to: Michael Schaefer, PhD

Department of Neurology
Otto-von-Guericke University Magdeburg
39120 Magdeburg, Germany
Tel.: +49(0) 391-6117542
Fax: +49(0) 391-6715233
Email: mischa@neuro2.med.uni-magdeburg.de
174 Michael Schaefer
1. INTRODUCTION: BEING A MONSTROUS BUG

One morning, as Gregor Samsa was waking up from anxious dreams, he discovered that
in bed he had been changed into a monstrous verminous bug. He lay on his armour-hard back
and saw, as he lifted his head up a little, his brown, arched abdomen divided up into rigid
bow-like sections. From this height the blanket, just about ready to slide off completely, could
hardly stay in place. His numerous legs, pitifully thin in comparison to the rest of his
circumference, flickered helplessly before his eyes. What's happened to me, he thought. It
was no dream.
This is the beginning of the famous novel The Metamorphosis by Franz Kafka, in
which the hero suddenly awakes with having the body of a bug, including a huge appetite on
rotten apples and similar food. Kafkas work used this metamorphosis as a metaphor to
describe how odd we sometimes feel in our body and life. And in deed, we all sometimes feel
a little bit displaced in our body, like an ugly bug whose thoughts and feelings nobody
understands and all want to get rid of or to be changed into a more ordinary person. The
astonishing idea of Kafkas novel was that Gregor Samsa on this morning did not just feel like
a bug, he was a bug: It was no dream. On the one hand, this idea makes the story similar to
fairy-tales we heard in our childhood. On the other hand, the rest of the story stresses the
reality of this novel - it was not a nightmare for Gregor Samsa, it really happened to him.
Both parts together may explain the fascination we feel when reading this novel.
The experiments we report in this review are about the feeling of our own body and about
the establishment of an early concept of our self. As we will see below, recent studies provide
evidence that even at early stages of somatosensory processing important processes of body
perception and body differentiation seem to take place. The studies will focus in particular on
the primary somatosensory cortex (SI), a major node in early sensory processing. In this
review we will argue that even at this early gate body and mind are closely interwoven.
2. SI PERCEIVES INFORMATION RATHER THAN REFLECTING IT IN A

MECHANICAL WAY
1937 Penfield and Boldrey were the first ones who discovered that a region on the human
postcentral gyrus represents the surface of our body in a topographic map: the primary
somatosensory cortex or SI (Figure 1). Any physical stimulation of the body surface is
represented in this primary somatosensory area. Moreover, this map shows systematically the
tactile sensitivity of each body area. Body parts with low receptor densities are represented by
small areas in SI and body parts with a high sensitivity to tactile stimulation (e.g., the tongue)
are represented by relatively big areas. Thus, the resulting body image in SI is distorted in the
form of the famous somatosensory homunculus.
Touch and Body 175
Figure 1. The primary somatosensory cortex on the postcentral gyrus and the parts of the body it is
concerned with (cross-section through the cortex).
For decades researchers believed that the topography in SI is fixed already in early
childhood. It has been assumed that no new neural connections can be formed in the adult
mammalian brain: once those connections were built in early life, it was assumed that they
would remain fixed for the whole life. This was also used as an explanation why people learn
very fast in childhood but rather slow when they are adults. Similarly, this theory has also
been used to explain why there is often so little functional recovery after damage to the
nervous system.
This traditional view of an unchangeable body map representation in SI was questioned
by animal studies conducted by Merzenich and colleagues (1984). Several experiments
revealed that the amputation of a finger yielded in plastic changes in SI. For example,
Merzenich et al. (1984) found that two months after amputation of the middle finger of adult
monkeys the area of cortex corresponding to this digit was responding to tactile stimuli
delivered to the adjacent digits. Thus, this area has been taken over by tactile input of the
adjacent fingers. Similar experiments with monkeys were done by Pons et al. (1991). After
deafferentation of an upper limb they reported the cortical area once corresponding to the
hand was taken over by sensory input from the face. While the plastic changes in the studies
by Merzenich et al. was about one millimeter, here the results demonstrated sensory
reorganization over a centimeter. These results from animal data led to a new interest in
studies with upper limb amputees. Since upper limb amputees have lost an arm and a hand,
there is empty space in the functional topography in SI. No sensory information is coming
to the region that has been formerly innervated by the hand and arm. Thus, many researchers
speculated that the distorted body image in SI might be responsible for phantom limb
phenomena like phantom limb pain or referred sensations (Ramachandran, 1998;
Ramachandran and Hirstein, 1998). In 1994 Yang et al. employed the new technique of
magnetoencephalography (MEG) and used neuromagnetic source imaging to map the
topography in SI in upper limb amputees. They found that the cortical representation of the
mouth region invaded the region that formerly represented the amputated limb (see Figure 2).
This cortical reorganization was a prominent example of plastic changes in the brain. Thus,
even the adult brain seemed to be able to change after injuries. Subsequent research extended
these reports by showing that these plastic changes are not related to all phantom limb
phenomena, but strongly correlated with the degree of phantom limb pain (Flor et al., 1995).
Figure 2. Cortical reorganzation in upper limb amputees. The cortical representation of the mouth
region (yellow triangle on the amputated side) was found to invade the region that formerly represented
the amputated limb (see red arrow). This cortical shift of the mouth representation correlated highly
with the magnitude of phantom limb pain.
When Penfield and Boldrey (1937) described the somatosensory homunculus, they
proposed a body map that was not only supposed to be fixed, but also was considered as
representing the physical image of the body in a relatively mechanical way. As shown above,
recent research has questioned this view. Previous studies suggest that the topography in SI
represents the perception of tactile stimulation rather than the physical location of touch
delivered to our body. Thus, the somatosensory homunculus may code a first image of the
body based on the perceived situation of the received touch, in contrast to the mere reflection
of physical stimulation in a mechanical way.
An important experiment providing support for this hypothesis is reported in an animal
study by Chen et al. (2003). The authors were interested in the role of the somatosensory
Touch and Body 177
cortex during the tactile funneling illusion. The funneling illusion consists of a simultaneous
stimulation of two points on the skin, which produces a single focal sensation at the center of
the stimulus pattern, even when no physical stimulus occurs at that site. Chen et al. (2003)
used the technique of optical imaging to examine the role of SI (Area 3b) in monkeys during
this illusion. They reported that simultaneous stimulation of two fingertips produced a single
focal cortical activation located between the expected regions for each single fingertip
activation. Thus, the authors concluded that the topographic organization in SI reflects the
perceived rather than the physical location of peripheral stimulation.
Further evidence came from subsequent studies with human subjects. Using functional
magnetic resonance imaging (fMRI), Blankenburg et al. (2006) similarly examined a
somatosensory illusion that can dissociate tactile perception from physical stimulation. The
so-called cutaneous rabbit illusion consists of repeated rapid stimulation at the wrist followed
by the skin near the elbow. This procedure evokes the illusion of touches at intervening
locations along the arm, as if a rabbit hopped along it. FMRI results revealed that illusory
sequences activated contralateral SI at a somatotopic location corresponding to the filled-in
illusory perception on the forearm (compared with a control condition). The authors
concluded that illusory somatosensory perception affected SI. Moreover, the results
demonstrated that this activation was somatotopically organized, providing additional support
for our hypothesis.
The understanding that the functional topography in SI may reflect the perceived shape of
the body rather than physical aspects of peripheral stimulation was further supported by
neuromagnetic studies on multisensory integration. It has been long established that vision
often dominates the tactile modality (e.g., Rock and Victor, 1964). Thus, simple
manipulations of multisensory integration may result in tactile illusions (e.g., Ramachandran
and Rogers-Ramachandran, 1996; Ramachandran, 1998). In order to test the hypothesis that
brain activity at early stages of sensory processing is susceptible for tactile illusions, we
created an experiment to evoke the illusion of a referred sensation while examining
neuromagnetic activity in SI (Schaefer et al., 2006a). The astonishing phenomenon of referred
sensations sometimes happen in amputees. Referred sensations are felt in their phantom and
can be triggered by certain points on the body, e.g. the cheek or the shoulder, sometimes even
in a topographic manner (Ramachandran, 1998).
Here, we were interested in an illusion of a referral of a somatic sensation on another
body part. Hence, we tried to induce a referred sensation in healthy individuals similar to that
reported in phantom limb patients. While recording their brain activity with MEG, subjects
watched a video that showed a hand that was stroked by a stick on the thumb while actually
receiving real tactile stimuli on the fifth finger. The video was presented in the peripersonal
space of the subject at a distance where the real hand would be expected. Thus, we created an
experimental conflict between tactile and visual senses. Due to the known dominance of the
visual modality over somatosensation (Rock and Victor, 1964), we hypothesized that the
participants would feel the stroking on thumb instead of the fifth finger. Therefore, we
described this tactile illusion as an artificially induced referred sensation. Moreover, we
hypothesized that SI is prone to this kind of visuo-tactile illusions. When the topographic
organization in SI reflects the perceived rather than the physical location of peripheral
stimulation, the functional topography should be affected by the illusion.
Figure 3. Dipole sources of the somatosensory evoked fields of the thumb (squares) and fifth finger
(circles). Differences between thumb and fifth finger during the illusion condition (in-phase) and
control condition (out-of-phase) and rest are clearly visible.
Results revealed that subjects felt the illusion of being touched on thumb instead of the
fifth finger, demonstrating that we successfully induced a visuo-tactile illusion in our
participants. Neuromagnetic source imaging based on tactile stimulation with a pneumatic
stimulation device (Schaefer et al., 2004) revealed that this tactile illusion was accompanied
by changes in the topography of the functional organization of SI (see Figure 3). The cortical
representation of the fifth finger shifted towards a more posterior location, pointing to an
enlargement of the cortical representation. The amount of the referred sensation (or of the
illusion) was significantly correlated with the modulation in SI: The more the subjects felt
being touched on the thumb (instead of the actually stimulated fifth finger), the more SI was
modulated. Thus, the results confirmed that in contrast to traditional views of the body map
the topographic representation in SI reflects the perceived rather than the physical location of
peripheral stimulation. Further, these findings demonstrate that not only illusions based on
modulations in the tactile modality (e.g., the funneling illusion or the cutaneous rabbit
illusion) may alter the somatosensory topography, but also illusions based on manipulations
of multisensory integration. Hence, the results point to multisensory processing in SI, an area
of the brain that long has been regarded as being strictly unimodal.
Why was the cortical representation of the fifth finger moved to a more posterior position
when subjects felt being illusory touched? Classical studies demonstrated that there are
several digit representations in the parietal lobe (area 3b, 1, 2, 5) (e.g., Kaas et al., 1979).
Areas 3a and 2 of the somatosensory cortices have dense reciprocal connections with the
motor system and the PPC, in which bimodal neurons were found. Feedback from these areas
may have influenced somatosensory processing. Area 2 has connections with the rostral part
of the PPC that receives visual input from the more caudal parts of the PPC. This might have
potentiated activity in area 2 in this study, resulting in the posterior shift of the fifth finger.
It remains unclear if the tactile illusion of a referred sensation demonstrated in this study
is based on similar neural circuits than referred sensations known in patients with phantom
limbs. The observation that phantom sensations could be evoked from the intact and the
amputated side (pointing to an involvement of SII) as well as from distal areas (Grsser et al.,
Touch and Body 179
2004) and the fact that there is cortical reorganization not only in SI (Flor et al., 1995) but
also in the thalamus (Jones and Pons, 1998) and motor cortex (Karl et al., 2001), seem to
point to a multifactorial model of the origin of phantom limbs.
3. FEELING AN ALIEN HAND: THE CASE OF THE RUBBER

HAND ILLUSION
In general, healthy subjects know very well what belongs to their body. However, as
shown above, simple manipulations in multisensory integration can induce profound tactile
illusions. Based on these simple manipulations Botvinick and Cohen (1998) reported an
intriguing finding. They instructed participants to watch a rubber hand placed on a table in
front of them. Their real right hand was hidden. Now the experimenter touched both, the real
right hand as well as the rubber hand, with a small paintbrush. Subjects perceived touch
sensations as arising from the rubber hand when both the rubber hand and their own real
hidden hand were repeatedly tapped in synchrony (Botvinick and Cohen, 1998; Armel and
Ramachandran, 2003). Thus, subjects had the feeling as if the rubber hand belongs to their
own body. This illusion disappears when a small asynchrony is introduced between the
stroking of the rubber and the real hand.
To further test whether the rubber hand illusion engages SI, we conducted an MEG study
(Schaefer et al., 2006b). We recorded neuromagnetic fields while subjects watched a video
showing a hand that was stroked by a stick on the thumb. At the same time subjects were
stimulated on their real thumb, synchronously or asynchronously to the stimulated hand in the
video. The video was displayed in the peripersonal space of the subjects. Based on the
findings of Botvinick and Cohen (1998) we assumed that during synchronous stimulation the
subjects would experience an illusion of feeling the touch on the hand in the video. We
further hypothesized that the cortical representation of the thumb would be modulated,
suggesting dynamic short-term modulations of cortical maps related to this illusion.
Figure 4. Dipole localizations of the somatosensory evoked fields. Note the differences between rest or
asynchronous condition (control condition) and synchronous (experimental or illusion) condition.
Figure 5. Mean differences (group data) between thumb and fifth finger dipoles during rest,
asynchronous (control) and synchronous (illusion) condition (fifth finger always rest state). Asterisks
indicate the significant differences between the synchronous (synchro) and asynchronous (asynchro)
condition and rest, respectively.
Behavioral results showed that in the synchronous stimulation condition subjects reported
an illusion in which they stated to feel being touched on the hand in the video and to feel the
video hand as their own hand. Results of the neuromagnetic source imaging revealed that the
cortical representation of the thumb changed to a more inferior location during synchronous
(the illusion condition) in comparison to asynchronous stimulation and baseline (Figures 4
and 5). Moreover, this change was significantly positively correlated with the amount of
feeling the touch on the video hand and the degree of feeling the video hand as their own
hand. Thus, the data suggest that somatosensory cortical maps contribute to the experienced
illusion in which the subjects seemed to feel the applied touch on the video hand. But only if
the seen touch was attributed to the own body, SI seemed to be modulated. Hence, the results
demonstrate that viewing touch in peripersonal space changes somatosensory processing in SI
when it is believed to occur on the own body part.
4. FEELING THE BODY OF OUR CONSPECIFIC: THE

CASE OF EMPATHY
The results of the study discussed in the previous paragraphs (Schaefer et al., 2006b)
bring up some further questions. To what extent are the somatosensory cortices capable to
Touch and Body 181
understand touch seen on a body? Perhaps the somatosensory cortices already may be
activated merely by the observation of touch, in the absent of any real touch? In other words,
is there something like a mirror neuron system for observed and experienced touch, analogue
to the mirror neuron system for action observation?
The mirror neuron system for action observation has been introduced by Rizzolatti et al.
(1996a). Previous animal studies have found so-called mirror neurons in monkey area F5.
These neurons discharge with the performance of goal directed actions and also with
observation of another individual performing a similar action (Di Pellegrino et al., 1992;
Gallese et al., 1996; Rizzolatti et al., 1996a, Rizzolatti et al., 1996b). The properties of the
neurons may build the neural basis for a mechanism that allows matching between visual
description of an action and its execution. Thus, a mirror neuron system for action
observation is suggested. This mirror neuron system for action observation may be related to
action recognition and action understanding. Action understanding means to get an internal
description of an action, which might be used for organizing appropriate behavior. According
to the mirror theory, this is not based on the visual analysis of different elements of the
observed action and subsequent inferences. Rather, this is based on the mapping of visual
representation of the observed action onto our motor representation. Hence, we understand
others through an internal act that recaptures the sense of their acting (Rizzolatti et al., 2001).
An increasing body of evidence suggests a mirror system in humans similar to that
described in the monkey. Imaging studies propose the presence of mirror neurons in several
cortical areas, in particular the ventral premotor area, which is the homologue region to the
monkey F5 area (Rizzolatti et al., 1996; Grafton et al., 1996; Iacoboni et al, 1999; 2005;
2006; Buccino et al., 2001; Avikainen et al., 2002). Further, a number of studies suggest an
involvement of the primary motor area, which might be activated through premotor areas
(Fadiga et al., 1995; Gangitano et al., 2001).
Several animal studies also found neurons in the parietal cortex, which are responding
both to tactile stimulation and to visual stimuli (e.g., Iriki et al., 1996; Graziano, 1999).
Further, recent evidence suggests that some neurons in SI are able to code arbitrary visual-
tactile associations: Animal studies have shown that neurons in monkey SI may fire both in
response to a tactile stimulus, and also in response to a visual stimulus previously associated
with the tactile stimulus (Zhou et al., 1997). Some of these neurons even showed sustained
activity during the visual-tactile delay period, thus suggesting a cross-modal short-term
memory (Zhou et al., 2000). This process could involve either a local mechanism within SI,
or interactions with other cortical areas, or a combination of both. The interaction with the
parietal cortex may involve bimodal neurons, which are sensitive both for vision and touch.
Hence, analogue to the mirror system for action observation, a possible mirror system for
observing and receiving touch may exist. This mirror system might be based on the activation
of sensory cortical areas, which are linked to areas containing bimodal neurons.
Understanding of the sense of observed touch is an essential ability. Touch can be meant
friendly, dangerous, or goal directed. According to the mirror theory, observation of touch
might be important for the recognition and understanding of the touch, for getting an internal
description, understanding of what happens and to organize appropriate behavior. In other
words, a mirror system for observed touch is close to the concept of empathy.
The neuronal correlates of observing touched body parts are mainly unknown. In order to
determine the pattern of brain activation related to the observation of touch, we conducted an
fMRI study, in which subjects watched a video showing a hand that is touched on the index
finger by a paintbrush in a repetitive way (Schaefer et al., 2010). In a control condition the
subjects watched again the video hand and the paintbrush, but this time the paintbrush did not
touch the hand. Thus, the control condition included the same motion and visual aspects as in
the experimental condition. Subjects viewed a touched hand either in an allocentric view or in
an egocentric perspective (in the absence of any real touch) (Figure 6). We hypothesized that
the observation of tactile stimulation would led to an activation of SI, similar to the activation
evoked by real stimulation with the paintbrush. This would give an important hint for a mirror
system for observed and received touch.
Figure 6. Types of stimuli used in the experiment: On the right the touch-condition; on the left the non-
touch condition. The upper panel depicts the hand in egocentric perspective, the lower in allocentric
perspective.
Figure 7. Brain response for observed touch (relative to nontouch) in egocentric perspective compared
with neural activations for allocentric perspective, superimposed on the MNI reference brain. Results
show significant posterior activation of SI for the allocentric perspective (BA 2) relative to the
egocentric perspective (BA3a, 3b).
Touch and Body 183
The results revealed activation of somatosensory cortices (SI and secondary

somatosensory cortex, SII) when observing a hand being touched in egocentric as well as in
the allocentric perspective, in the absence of any real touch on the own hands (see Figure 7).
Thus, a touched hand that we are only watching in a movie is sufficient to evoke an activation
of our somatosensory cortices, a region that once was thought to merely reflect physical
stimulation on our own body!
Moreover, the somatosensory cortices seem to be activated differentially depending on
the perspective of the observed touch. Whereas the egocentric perspective showed activation
in the anterior part of SI (BA3a, 3b), the allocentric perspective involved significant
activation of the posterior part of SI (BA2) (Figure 7). BA 2 has multimodal receptive fields
and connections to the rostral part of the posterior parietal cortex, which in turn receives
visual input from more caudal parts of the posterior parietal cortex (Iwamura, 1998). Thus,
the connectivity between these regions may be related to the activation in BA2. Viewing
touch in an egocentric condition may have induced self-attribution/imagination of being
touched on ones own hand, which is different from observing touch on another hand and
might require less multimodal activation in BA2. Thus, feeling or imagining being touched
oneself may engage a slightly different neural network that requires less multimodal
activation in BA 2.
The results of another recent study support the idea of a functional dissociation in SI.
Ebisch et al. (2008) used fMRI to examine whether the tactile mirror mechanism applies to
the sight of any touch irrespective of the intentionality of the observed touching agent. They
found a shared neural circuitry for touch in SII and a significant difference between the sight
of an intentional touch compared to an accidental touch in left SI/BA2. The activity in
SI/BA2 was correlated with the degree of intentionality of the seen touch. The authors
concluded that this activity in SI may reflect a human tendency to resonate more with an
intentional touch agent than with accidentally touched object. The results of our study are
consistent with the findings reported in Ebisch et al. (2008) and further suggest that SI/BA2
may differentially respond to non-egocentric body contact.
Taken together, SI seems to be differentially engaged depending on whether observed
touch is attributed to the own body or to someone else. Moreover, different parts of SI seem
to provide different functions regarding the differentiation of self and others and also
depending on the perceived intentionality of the seen touch. These results extend the findings
of our previous study we discussed in the chapter before (Schaefer et al., 2006b). Hence, we
conclude that SI seems to be involved when perceiving social situations.
The activation of somatosensory areas when observing touch provides evidence for a
possible mirror neuron system for observed and experienced touch. The results are in line
with similar findings regarding activation of SI and SII when observing a touched face
(Blakemore et al. 2005), or leg (Keysers et al., 2004). A study employing the method of
electroencephalography (EEG) provided further insights. Bufalari et al. (2007) reported that
somatosensory evoked potentials (SEPs) were modulated by the mere observation of a
touched hand. They reported increased (and decreased, respectively) amplitudes of the P45
somatosensory evoked potential (SEP) component when observing a hand receiving
nonpainful touch or painful stimulation. The authors concluded that SI is not only involved in
the actual perception of touch but also in extracting somatic features from social interactions.
In other words, SI seems to play an important role for empathy.
This is also supported by other recent studies. Several studies linked SI with empathic
abilities of the participants (e.g., Cheng et al., 2008; Betti et al., 2009), suggesting that
sensory enrichment (accomplished by activation in SI, Keysers et al., 2010) in the mirror
network may also be described as empathy. For example, Ruby and Decety (2004)
demonstrated that perspective taking and empathy engages a network of different brain
regions including SI. The authors employed positron emission tomography (PET) to examine
the interaction between emotional and perspective factors. The participants were asked to
adopt either their own perspective (egocentric viewpoint) or the third person perspective of
their mothers in response to situations involving social emotions or to neutral emotions. The
contrast third person perspective relative to first person perspective hemodynamic revealed
increases in the medial superior frontal gyrus, superior temporal sulcus, left temporal pole,
posterior cingulate and left inferior parietal lobe. For the contrast first person perspective
relative to third person perspective a cluster in the postcentral gyrus (SI) was involved.
Interaction effects between social emotions and perspective taking were identified in the left
temporal pole and in the right postcentral gyrus (SI). Thus, the results suggest an important
role for SI in understanding social emotions and empathy.
5. CONCLUSIONS: SI AND IDENTITY

This review focused on the role of SI for establishing an early form of identity. The
studies presented above showed that in contrast to classic views SI reflects the perceived
information on our body rather than physical information of peripheral stimulation.
Perception means that SI seems to choose and weighten information in order to understand
what is happening with our body and in the space surrounding us. Thus, the meaning of touch
that takes place on the surface of our body is crucial for coding it in our somatosensory
homunculus. In other words, even SI actively interprets information rather than simply
transport them into the cortex. Evidence for this new role of SI came from experiments with
tactile illusions. Furthermore, some recent studies demonstrated that the body image coded in
SI is also involved when the brain has to decide if an observed touched body part belongs to
the own or someone elses body. Last, there is also an increasing body of evidence suggesting
a role of SI for empathy.
We draw three main conclusions out of these results. First, we think that the body image
seems to be extremely flexible and permanently updated based on multisensory information.
On the one hand, this may explain why distortions of the body image after amputation of a
limb or as a result of anorexia nervosa happen so easily. On the other hand, this also
encourages new therapeutic approaches based on visuo-tactile manipulations in order to
change the body image in a more appropriate way.
Second, we think that the studies here discussed point to a role for SI in establishing a
first major concept of self-identity. Since the experiments have shown that SI differentiates
between touch seen on other body parts and on the own body, we believe that even at this
early step of processing tactile information an image of our own (or of our own body) is
maintained. Later stages in the establishment of identity may subserved by areas in the
parietal in frontal areas (e.g., premotor cortex, posterior parietal cortex). Further, there may be
Touch and Body 185
other (even earlier) body images established in the thalamus or in the superior colliculi. All
these body images may contribute to a coherent feeling of our bodily self.
A third insight from the studies here reviewed is the link to the social world. Although
touch in the past often was neglected, there is no doubt about the importance of touch in our
everyday social interactions from birth through to adulthood and old age. Since SI seems to
code the difference self vs. other, it also bears a first major node in processing and
understanding social information. For the concept of identity it is always necessary to include
the notion of the other. Thus, identity and social cognitions are closely interwoven and
cannot be seen isolated. It seems remarkable that cortical areas related predominantly to
tactile processing of touch experienced on the own body may perceive social information.
However, phrases like Lets keep in touch point to the fact that experienced or observed
touch are important signs that help us to understand social situations. To understand and
assess a social situation the touches we observe often seem to be more important than the
observed actions. The reason for that may be that touch towards someone else can be an
extremely positive sign, but also a very dangerous mark that signals harm to the conspecific
(and potentially to the observer, too). Further, when we observe a social situation we often
perceive a lot of movements and gestures, but only very few touches towards another bodies.
In fact, in real life most of the interactions we observe do not include touches towards the
other at all. Hence, the touch we observe in social situations often may give us much more
and more important information than actions not including touch. Thus, observed touch often
provides us with important social cues in our daily life. This even may include touches we
have seen or experienced long ago in the past and we still keep it in our memory.
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Chapter 10
NOTHING COMPARES TO YOU: THE INFLUENCE OF

BODY SIZE OF MODELS IN PRINT ADVERTISING AND
BODY COMPARISON PROCESSES ON WOMENS
BODY IMAGE
Doeschka J. Anschutz*, Tatjana Van Strien,, Eni S. Becker and

Rutger C.M.E. Engels
Behavioural Science Institute
Institute for Gender Studies
Radboud University Nijmegen, The Netherlands
ABSTRACT
Associations between body size of print advertising models, body comparison
processes and body-focused anxiety were examined. Normal-weight females viewed
advertisements of slim models, or the same models horizontally stretched to make them
look more average sized. Participants were instructed to focus either on the positive or
the negative features of the models. The results showed that when participants viewed
average sized models, they felt better about their own body, regardless of body
comparison instruction. Interestingly, when participants focused on negative features of
the models, they also felt better about their own body, regardless of body size of the
models.
*
Corresponding author: Doeschka J. Anschutz
Behavioural Science Institute
Radboud University Nijmegen
P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
Phone +31 24 3611818; Fax +31 24 3612776
E-mail: d.anschutz@pwo.ru.nl
190 Doeschka J. Anschutz, Tatjana Van Strien, Eni S. Becker et al.
INTRODUCTION
It is generally agreed that the thin beauty ideal provided by the mass media has a negative
influence on the body image and eating behavior of girls and young women (e.g., Field et al.,
1999; Harrison & Cantor, 1997; Posavac, Posavac, & Weigel, 2001; Stice, Spangler, &
Agras, 2001). However, instead of becoming more realistic, the media images women are
exposed to these days still represent very unrealistic female bodies and they seem to get even
thinner (Sypeck, Gray and Ahrens 2004). In current Western societies, women are daily
exposed to this thin beauty ideal, and it seems that this can hardly be avoided. The present
study examined the interaction between body size of media images and body comparison
processes on young womens body image.
Women might feel dissatisfied with their own bodies after exposure to thin models in
print advertising, because these images are quite unrealistic in comparison with the actual
body of most women (e.g., Dittmar & Howard, 2004; Halliwell & Dittmar, 2005; Stice &
Shaw, 1994). For example, Smolak (1996) found that fashion models are thinner than 98% of
the American women. When exposed to these advertising models women experience a
discrepancy between their own body size and the models body size, which might lead to
negative feelings about their own body and maybe even behavioral changes to attain a thinner
body (i.e. exercising behaviour). The social comparison theory (Festinger, 1954) provides a
framework that might explain the relations between exposure to thin media images,
subsequent attitudes towards ones own body and possible behavioural changes. This theory
states that people (automatically) compare themselves to other persons or images that
represent goals they want to achieve (see also Botta, 1999). According to the social
comparison theory people tend to compare themselves only with others that are similar or
relevant to them. Although one might argue that advertising models are probably not alike
and therefore not relevant for the average women to compare themselves with, the contrary
appears to be true. Strahan, Wilson, Cressmann, and Buote (2006) argued that models and
celebrities can be seen as representations of the current beauty ideal, and because women
know that they will be judged according to these cultural beauty standards it is relevant to
compare themselves with these media images. They experimentally tested the effects of
exposure to thin ideal and neutral advertisements on body dissatisfaction. It was found that
women had a higher tendency than men to make upward body comparisons with unrealistic
targets than men, and when they compared themselves with advertising models they felt
worse about their own bodies afterwards. In addition, Martin and Kennedy (1993) found that
the tendency of pre-adolescent and adolescent girls to compare themselves with
advertisement models increased with age and was higher in girls with low self-perceptions of
attractiveness or low self-esteem. Advertising models are relevant sources for girls to judge
themselves by and to gather information from about attractiveness, while in fact body
comparison to advertising models is related to body dissatisfaction (Jones, 2001). So, we can
conclude from the current literature that women do compare themselves with advertising
models even though they might feel worse about themselves afterwards.
In the present study we use the term body comparison instead of social comparison,
since the kind of comparison we were interested in focuses especially on the body, so we
considered body comparison a more suitable term to use than the more general term social
comparison. A distinction can be made between trait and state body comparison. Some
Nothing Compares to You 191
women generally have a high tendency to compare their appearance with the appearance of
others, which we refer to as trait body comparison. The trait body comparison was found to
be related to body dissatisfaction (Stormer & Thompson, 1996). When women compare their
bodies with those of advertising models, it seems likely that these comparisons will be
upward and a positive judgement of advertising models might subsequently lead to a more
negative judgement of their own body (see also Richins, 1991). The question arises whether it
is possible to change this automatically upward comparison process. To prevent an increase in
body dissatisfaction after exposure to slim models it may be helpful to gain insight into
whether young women are able to change the way they compare themselves with these
models. Only a few experimental studies addressed this question and manipulated state body
comparison. Martin and Gentry (1997) exposed pre-adolescent and adolescent girls to
magazine advertisements and manipulated the motives the girls used for comparison with the
advertisement models by varying the instructions and advertising headlines. The girls either
had to evaluate their own physical appearance in comparison with that of the model (self-
evaluation motive), compare their appearance with that of the model in order to find ways to
improve their own appearance (self-improvement motive), find ways in which they were
prettier than the model (self-enhancement motive), or just had to try to discount the beauty of
advertisement models and to avoid making an explicit comparison (protection/maintenance
self-esteem motive). The overall results showed that the self-evaluation motive had a negative
impact on body image, contrary to the other motives. These results were supported by
Halliwell and Dittmar (2005) who demonstrated that after exposure to thin model images,
women experienced higher body focused anxiety if they focused on self-evaluation, whereas
women who focused on self-improvement experienced equal body focused anxiety when they
viewed thin models or no models. In sum, the results of previous studies suggest that body
comparison processes play an important role in the relation between thin ideal exposure and
body image disturbance, but more research is needed.
The present study is the first to compare the effects of advertising models body size on
body image with the effects of focusing on the positive or negative features of the models in
comparison with ones own appearance. Young women viewed images of fashion models that
were either originally thin or were manipulated (by using computer techniques) to look more
average sized. Many previous studies compared the effects of advertisements using thin
models to the effects of neutral advertisements, or used different models across thin- and
average sized model advertisement conditions. However, these studies can not draw firm
conclusions concerning the question whether using thin models in advertisements causes
women to feel worse about themselves than advertisements using more average sized models.
Therefore, we used the same models across conditions to avoid that individual differences
between the models (i.e. attractiveness and clothes) would affect our results. Additionally, we
tried to manipulate the way the women perceived these images by instructing them to focus
on the positive or negative features of the media model in comparison with themselves. We
controlled for BMI and trait body comparison of the participants, because both variables
might influence the relation between thin ideal media exposure and body focused anxiety. It
was hypothesized that women would feel worse about their own bodies when the advertising
models they were exposed to were thin models, as compared to the average sized models.
However, focusing on the negative features of the thin models would prevent an increase in
body dissatisfaction in women.
METHOD
Participants
The sample consisted of 107 normal weight female students, all recruited at the Radboud
University Nijmegen. They had a mean age of 20.7 (SD = 3.7) and their average body mass
index (BMI = weight/height) was 21.4 (SD = 1.9). Participants with BMI scores above 25
were not included since we hypothesized, based on the literature, that the processes involved
in body focused anxiety are different for overweight individuals compared to normal weight
individuals (e.g., Annis, Cash, & Hrabosky, 2004; Thompson et al., 2007).
Procedure
The study was presented to the participants as an investigation of decision-making

processes in composing advertisements. They were told that we aimed at composing an
advertisement for a new (unknown) perfume and that they had to select the model they
considered most appropriate for this advertisement. We presented them a picture of the
perfume bottle and 10 images of fashion models, taken from various magazines. About half of
the participants (n = 51) was exposed to the original, thin images, whereas the other half (n =
56) was exposed to the same images that were horizontally stretched for 20% (see also
Halliwell & Dittmar, 2005). This was possible without participants noticing that we
manipulated the images. By stretching the images the models looked more average sized. We
told them that because we were interested in the underlying mechanisms of their choice for a
certain model, for every model they had to write down what they liked (n = 50) or disliked (n
= 57) about the models body in comparison to themselves. So, four conditions were created;
thin models/liking, thin models/disliking, average sized models/liking and average sized
models/disliking. The assignment took about 15 minutes. After the assignment the
participants had to answer some questions that supported the cover story, and some questions
about their attitudes towards the models were embedded. After this, the images were removed
and the participants were asked to fill out the questionnaires about their body focused anxiety
and trait body comparison. Subsequently, participants height and weight were measured by
the experimenter. Finally, participants were paid or given course credits for participating.
Debriefing took place after complete data collection was finished.
Measures
Attitudes Towards the Models

Immediately after the assignment participants were asked to indicate on two 14 cm
Visual Analogue Scales (VAS) to what extent they considered the models attractive and slim,
ranging from not at all to very much. These scales were used to investigate whether our
manipulations (body size and comparison instruction) influenced the attitudes the participants
had towards the images.
Comparison Tendency
To measure the general tendency (trait) to compare ones own appearance with the
appearance of others we used the Physical Appearance Comparison Scale (PACS: Thompson,
Heinberg, & Tantleff, 1991). This scale consists of 5 items, with response categories ranging
from 1 never to 5 always. Participants had to indicate to what extent they agreed with a
statement, e.g. In social situations I compare my body figure to the body figure of other
women. In our sample, Cronbachs alpha coefficient for this scale was .66, which is similar
as in studies of Halliwell and Dittmar (2005) and Tiggemann and McGill (2004).
Body Focused Anxiety

To assess the participants body focused anxiety we used the Physical Appearance State
and Trait Anxiety Scale (PASTAS; Reed et al. 1991). Because we were only interested in the
weight related items and not in non-weight-related body parts, we computed a weight related
subscale of 7 items (the extent to which I look overweight, thighs, buttocks, hips, stomach,
legs and waist). Participants were asked to indicate how anxious they felt about the weight
related body parts at that moment, response categories ranged from 1 not at all to 5 very
much. Originally, Reed et al. (1991) included muscle tone as well in the weight-related
subscale, but as we did not consider muscle tone a weight related item, we left the item out
of our scale. Cronbachs alpha coefficient was .85 in our sample.
Strategy for Analyses

First, we examined the effects of our body size and comparison manipulation on how
attractive and slim the participants considered the models by using one-way ANOVAs. We
calculated effect sizes (Cohens d) by dividing the difference between the means by the
pooled standard deviations. Hence, the effect sizes may be viewed as the difference between
the groups, expressed in standard deviation units. Effect sizes between 0.2 and 0.5 reflect a
small effect, effect sizes between 0.5 and 0.8 a moderate effect and effect sizes above 0.8 a
large effect (Cohen, 1988).
To investigate whether the comparison and/or body size manipulation had a main-effect
and/or interaction effect on body focused anxiety, a regression analysis was conducted with
body focused anxiety as dependent variable. We controlled for BMI and trait appearance
comparison, since these two variables could possibly influence the effects of our
manipulations of the body size and comparison task on body focused anxiety. The
independent variables were entered into the equation in the following order: (1) BMI and
comparison tendency, (2) comparison task and body size, (3) comparison task x body size. .
Using regression analyses has several advantages including higher estimates of effect size,
increase of statistical power and a decreased risk of type I errors (Maxwell & Delaney, 1993;
Whisman & McClelland, 2005).
RESULTS
Descriptive Statistics
Table 1 shows the means and standard deviations of all variables in the four conditions.
In general, the models were rated as considerably attractive and slim. Participants scored
relatively high on comparison tendency which might indicate that female students in general
have the tendency to compare their appearance with the appearance of other women.
Table 1. Means (SD) Of All Model Variables In The Four Conditions
Thin - Thin - Average Average Total

Liking Disliking sized - sized- group
(n = 26) (n = 25) Liking Disliking (N = 107)
(n = 24) (n = 32)
Attractiveness 9.85 11.10 7.76 (2.65) 10.35 (1.89) 9.82
models (1.82) (1.91) (2.38)
Slimness models 10.77 11.50 8.95 (2.81) 9.48 (2.77) 10.15
(2.29) (2.68) (2.79)
Comparison 2.90 2.97 (0.58) 2.80 (0.52) 3.16 (0.66) 2.97
tendency (0.71) (0.63)
Body focused 2.40 1.86 (0.52) 1.71 (0.47) 1.93 (0.77) 1.98
anxiety (1.09) (0.80)
Attitudes Towards the Models

To examine whether the comparison instruction had an effect on how attractive and slim
the participants considered the models, we compared the mean scores of the two comparison
conditions on the VAS of slimness and attractiveness. Further, we examined whether there
was a difference in slimness and attractiveness ratings between the women who were exposed
to the thin models and the women who were exposed to the average sized models.
No significant differences were found between the participants who had to write down
what they did not like about the models (M = 10.38, SD = 2.89) and those who had to write
down what they did like about the models (M = 9.90, SD = 2.69) on how slim they considered
the models, F (1, 105) = .80, n.s. Remarkably, participants who had to write down what they
did not like about the models had significantly higher ratings for attractiveness of the models
(M = 10.68, SD = 1.92) than participants who had to write what they did like about the
models (M = 8.85, SD = 2.47), F (1, 105) = 18.40, p < .001, Cohens d = 0.9.
Our manipulation of the body sizes of the models was successful, as the thin models were
actually perceived as slimmer (M = 11.13, SD = 2.49) than the average sized models (M =
9.25, SD = 2.77), F (1, 105) = 13.39, p < .001, Cohens d = 0.7. In addition, it appeared that
participants who were exposed to the thin models significantly rated the models higher on
attractiveness (M = 10.46, SD = 1.96) compared to the participants who were exposed to the
average sized models (M = 9.22, SD = 2.58), F (1, 105) = 7.76, p < .01, Cohens d = 0.6.
Body Focused Anxiety

The results of the regression analysis with body focused anxiety as dependent variable
are shown in Table 2. It can be seen that both control variables, BMI ( = .26, p = .004) and
comparison tendency ( = .36, p < .001) were positively related to body focused anxiety (step
1, R = .21, p < .001). Higher BMI scores as well as a higher tendency to make body
comparisons were related to higher scores on body focused anxiety. Additionally, the body
size manipulation and comparison instruction, together in step 2, explained a significant
amount of variance in body focused anxiety (R change = .07, p = .01). Participants who were
exposed to the average sized models had significantly lower scores on body focused anxiety
compared to participants who were exposed to the thin models ( = -.18, p = .04). Further,
participants who had to write down what they disliked about the models had significantly
lower scores on body focused anxiety compared to participants who had to write down what
they liked about the models ( = -.18, p = .05). Finally, a significant interaction effect was
found between the body size manipulation and the comparison instruction (step 3, R change
= .03, p = .05) . In the thin model condition participants scored higher on body focused
anxiety if they had to write down what they liked about the models compared to if they had to
write down what they disliked about the models. However, there was no difference between
the two comparison conditions in the average sized models condition. Figure 1 shows the
regression equations that represent the association between the body size of the models and
body focused anxiety in both comparison conditions.
Table 2. Hierarchical Multiple Regression Analysis With Body Focused Anxiety As

Dependent Measure (N= 107) And Body Size And The Comparison Task As
Independent Variables, Controlling For BMI And Comparison Tendency
Step at entry R R Change

1. BMI .26** .20 .20***
Comparison tendency .36***
2. Body size -.18* .27 .07**
Comparison Task -.18*
3. Body size x Comparison .17* .30 .03*
Task
* p < .05; ** p < 0.01; *** p < .001
Figure 1. Regression Slopes Representing The Association Between Body Size Of The Model And
Body Focused Anxiety In Both Comparison Conditions (Liking Vs. Disliking).
DISCUSSION
In the present study we tested the associations of body size of advertising models and
body comparison processes with body focused anxiety. The main finding of this study was
the interaction effect between body size and body comparison on body focused anxiety. When
participants viewed the average sized models, they felt better about their own body,
regardless of the body comparison instruction. Interestingly, when participants focused on the
negative features of the models, they also felt better about their own body, regardless of the
body size of the models.
The finding that women who viewed the thin models showed higher body focused
anxiety than women who viewed more average sized models is in line with the findings of
other studies (e.g., Dittmar & Howard, 2004; Halliwell & Dittmar, 2005; Stice & Shaw,
1994). Probably, because the discrepancy between their own body size and the body size of
the advertising models was less great in the average sized condition, at least for the fast
majority of the participants, the women in that condition showed lower body focused anxiety
than the women in the thin body condition. These findings suggests that when, for example,
print advertisements in fashion magazines would use less thin models, the female readerships
would feel better about their own bodies. Why would advertisers then use idealized images?
Richins (1995) suggested that idealized images in advertising lead to comparisons in which
the consumer falls short, resulting in dissatisfaction, unrealistic expectations or reference
points for the standards they believe they should achieve and increased striving to achieve the
idealized state. From a marketing point of view, this (temporary) drop in satisfaction might
stimulate consumers to buy the products promoted. However, in research examining
advertising effectiveness it was found that using normally attractive models (with respect to
facial attractiveness and body size) in advertising was more effective than using highly
attractive models regarding the attitudes and purchase intentions consumers had towards the
advertised products (Bower & Landreth, 2001; Tsai & Chang, 2007). Moreover, Bower
(2001) found that comparisons with highly attractive models in advertising was related to
greater experience of negative affect, which lowered the models credibility as a spokesperson
for the product, which on its turn is known to influence product evaluation and purchase
intentions. So, although it is common to use thin advertising models these days, marketers
might even benefit from using more realistic models. It would be an interesting suggestion for
future research to examine this hypothesis, for example by experimentally testing whether
womens purchase intentions and behaviours are affected differentially when they are
exposed to either advertisements using thin or advertisements using average sized models.
The results of the present study support the assumption that using more average sized models
would at least be advantageous for the female consumers, in that they feel better about their
own bodies when exposed to more average sized models.
Besides less thin, the average sized models were also rated as less attractive in the present
study. The finding that average sized models are considered less attractive only because they
were less thin is quite startling keeping in mind that it concerned the same individuals that
were rated in both body size conditions. It underscores the assumption that Western women
have internalized the thin beauty ideal and use it as a standard for attractiveness. It is possible
that if the media would use less thin models for a longer period, the thin beauty ideal could
change into a more average sized beauty ideal. Support for this supposition was found by
Peck and Loken (2004) as their results revealed that when average sized models are presented
in a context in which the emphasis is laid on breaking through the thin beauty ideal (a new
magazine in which explicitly larger sized models were used), women rate average sized
models as more attractive than when the context is in concordance with the current thin ideal
(a traditional thin ideal magazine). This suggests that when the context would change, and
women would be exposed more often to less thin models, this could also positively affect the
way they perceive these more average size models.
The results showed that body comparison processes affected body focused anxiety as
well. Trait body comparison was found to be related to body focused anxiety, which was also
reported by Stormer and Thompson (1996). Further, a main effect of the body comparison
manipulation on body focused anxiety was found, which is in line with previous studies
showing that upward comparison has a negative effect on body image, contrary to focusing
on self-enhancement (Halliwell & Dittmar, 2005; Martin & Gentry, 1997). Focusing on the
positive features of the models probably emphasized the negative features of the own body,
which appeared to cause body focused anxiety. In contrast, focusing on the negative features
of the models in comparison to oneself probably stressed the positive features of the own
body and therefore prevented body focused anxiety. An unexpected result was that
participants who had to focus on the negative features of the model felt better about their own
bodies, as well rated the models higher on attractiveness than participants who had to focus
on the positive features of the model. Perhaps women who feel better about themselves are
also more positive about others. Support for this assumption was found by Peck and Loken
(2004) showing that women with positive feelings about themselves tended to rate advertising
models higher on attractiveness than women who did not have such positive thoughts.
Another explanation is that focusing on the negative features of the models does not change
the perception of the attractiveness of the models but only prevents participants from feeling
worse about themselves. In contrast, women who explicitly have to focus on the positive
features of the models need to discount the models as a reaction to the increase in body
focused anxiety they experience. That would be in line with studies on discounting others in
order to feel better about the self, a well-known psychological mechanism (Baumeister, 1998;
Gibbons & McCoy, 1991). To conclude, the results show that besides the body size of the
models, also the way women look at them in when portrayed in advertisements in comparison
to themselves will influence body focused anxiety.
A limitation of the present study is that the setting we used might not be representative of
the daily life situation in which women are exposed to the media. Future studies should use
more naturalistic settings to be able to generalize the results to the daily life situation and to
decrease possible demand characteristics, for example by embedding the advertisements in
real magazines instead of showing separate images. We took great care to minimise demand
characteristics, by presenting the study to the participants as an investigation of decision-
making processes in composing advertisements. We cannot rule out, however, that implicit
demand characteristics may have affected the present study outcome. It is generally believed
that thin advertising models negatively affect body esteem and the present results are in close
correspondence with this general belief, so demand characteristics might have played a role in
this experiment. Furthermore, we do not know whether the effects would be the same when
using other media sources like television. It is possible that the processes involved in
exposure to televised images are different, for example because these images move (see also
Tiggemann 2003).
Changing the thin ideal used in advertising is complex due to the conflicting interests of
health institutions, manufacturers and advertisers. Advertisers might always stay primary
interested profit maximization and at the most be willing to change their advertisement
strategy if they see a clear (financial) benefit for themselves. For example, a certain brand
(Dove) is currently using more realistic women in their advertisement campaign.
However, since they still promote beauty enhancing products (e.g. firming gel) and other
brands of the same manufacturer (Unilever) still use very slim models, this campaign seems
to be more like a clever new advertisement strategy than driven by an idealistic motive to
enhance consumers welfare. Therefore, it might be useful to focus on changing the way
women perceive these ideals as well. Stice, Mazotti, Weibel, and Agras (2000)
experimentally tested an intervention program based on cognitive dissonance. In this three-
session intervention women had to come up with arguments against the thin ideal. They found
that young women who were encouraged to challenge socio-cultural standards regarding the
thin ideal experienced less negative effects of thin ideal exposure afterwards. These types of
theory-based interventions that focus on changing upward comparisons with advertising
models in comparison processes focusing on self-enhancement, similar to what we did in the
present study, to prevent women from feeling bad about themselves when viewing thin ideal
images, are needed. Rigorous tests of these interventions by using randomized controlled
trials, also facilitate testing of theoretical assumptions on the significance of comparison and
cognitive dissonance processes. In addition, not only college-age women, but also adolescent
or even pre-adolescent girls might take advantage by changing the ways they look at media
images. Future research is required to examine the effects of interventions focusing on body
comparison processes on body image, across age groups. Additionally, some previous studies
found that men are also susceptible for an ideal male image provided by the media (e.g.,
Hargreaves & Tiggemann, 2004; Leit, Pope, & Gray, 2001). It is important to test which
individual factors in men are related to higher susceptibility for thin ideal media, since less is
known about how men handle ideal images in the media yet. Another suggestion for future
research might be to measure not only the explicit evaluations of models, but also the implicit
attitudes that participants have towards the thin and less thin models. It is possible that on a
non-conscious level, women appear even more strongly affected by thin images in the media
than is now found in studies using more explicit assessments of evaluations.
The present study is the first to examine simultaneously the effects of body size of
models and comparison processes. The results are twofold: body size as well as body
comparison appear to play a role in the relation between media exposure and body focused
anxiety. So, the political discussion regarding the usage of unrealistic, thin models in
advertising should be continued. In the mean time, by changing the way they look at thin
ideals, women might be able to protect themselves from the negative consequences of
exposure to thin ideals.
NOTE
We examined whether the interaction we found would be moderated by BMI or
comparison tendency, but we did not find a three-way interaction between body size, the
comparison task and BMI or body size, the comparison task and comparison tendency on
body focused anxiety.
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Chapter 11
BODY IMAGE IN PEOPLE OF AFRICAN DESCENT: A

SYSTEMATIC REVIEW
D. Catherine Walker
The University at Albany, State University of New York, USA
ABSTRACT
In the United States of America, Black people are more likely to be overweight or
obese and are also more likely to suffer from many of the related chronic diseases. Based
on these data, it might be expected that Black men and women would suffer from greater
body image dissatisfaction. However, research suggests that Black women and Black
men are more satisfied with their bodies than are White women and men, respectively.
Historically, research on body image has been conducted using predominantly White
female samples. As a result, it is not clear whether or not the research generalizes to
young males, older men and women, and men and women from different racial and
ethnic backgrounds. The purpose of this chapter is to examine body image research in
people of African descent. Two questions that will be addressed are whether or not body
image differs in Black people compared to research that has been conducted using
primarily White participants, and whether body image has different relationships to
variables such as self-esteem, body mass index (BMI), and eating disorder symptoms in
these two groups. In addition, possible reasons for differences (e.g., mediators and
moderators) will be considered.
INTRODUCTION
In the United States of America, Black people are more likely to be overweight or obese
and are also more likely to suffer from many of the related chronic diseases (Brown, 2008;
National Center for Health Statistics, 2007; see Figure 1). Based on these data, it might be
expected that Black men and women would suffer from more body image dissatisfaction.
However, research suggests that Black women and Black men are more satisfied with their
bodies, respectively, than White women and men (e.g., Altabe, 1998; Aruguete, Nickleberry,
& Yates, 2004; Jones, Fries, & Danish, 2007; Smith, Thompson, Raczynski, & Hilner, 1999).
204 D. Catherine Walker
BODY SIZE PREFERENCE

In a study looking at body size preferences in Black and White students, White students
reported that they wanted a body size that was smaller than what they thought was healthy,
whereas Black students tended to prefer a body size that they considered to be healthy
(Aruguete et al., 2004). In this sample, Black participants believed that they were attractive
compared to White participants who judged themselves to be less attractive in the eyes of
others (Aruguete et al.). The same relationship between body image satisfaction in White and
Black males and females has also been found among rural adolescents (Jones et al., 2007). In
this sample, females wanted to be smaller and reported more body dissatisfaction than males,
with White females reporting the most body image dissatisfaction. Black adolescents of both
genders in this sample reported larger current and ideal figure ratings than White adolescents
and also preferred larger figures in members of the opposite sex (Jones et al.). In a large
sample of internet daters, White men were 75% more likely than Black men to select a
preference for thin and toned body type in women. A similar relationship was not found in
womens preferences for mens body types: no significant racial differences were found for
the preference of athletic body types (Glasser, Robnett, & Feliciano, 2009).
Because body satisfaction and body esteem typically covary in the majority of White
females, the difference between these two constructs may previously have been overlooked
(Tyler, Johnston, Dalton, & Foreyt, 2009). Body satisfaction refers to being satisfied with
ones body weight and shape, whereas body esteem refers to feelings about how one looks or
about ones overall appearance (Smolak & Levine, 2001). In a sample of Black girls in grades
3-5 from a predominantly Black student population, Tyler et al. found that although body
dissatisfaction and weight teasing increased with higher BMI in girls, body esteem did not
change. In other words, the Black girls in their sample who were overweight were not happy
with their current weight or size but they still felt good about their bodies and overall
appearance (Tyler et al.), suggesting that there may be additional factors that contribute to
body esteem in Black females that are distinct from shape and weight. Additional research in
students found similar rates of weight-related teasing among students of all races/ethnicities
(range: 41.5%-45.7% in girls and 32.1-41% in boys for different racial/ethnic categories), and
similar rates of boys bothered by the teasing across race/ethnicity, but significantly fewer
Black girls were bothered about weight-related teasing compared to children from other racial
and ethnic backgrounds (van den Berg, Neumark-Sztainer, Eisenberg, & Haines, 2008).
Among those teased by peers or family, 38.6% Black girls vs. 63.3% White girls were
bothered by peer teasing, and 43.8% of Black girls vs. 59.5% of White girls were bothered by
family teasing, supporting the idea that Black girls experience protective factors that buffer
against the negative psychological effects of weight-related teasing (van den Berg et al.).
Black men have different preferences in and are more accepting of a wider range of
female figures (Webb, Looby, & Fults-McMurtey, 2004). In a survey of undergraduate males,
they found that although Black and White men chose the same figure as m ost attractive,
Black men preferred larger women as the ideal woman to date compared to White
participants (Webb et al.). In addition, this relationship was moderated by degree of
acculturation to values common in African American communities: men who had high
acculturation scores were more likely to chose women with larger figures as ideal to date than
those with lower acculturation scores (Webb et al.). Although the authors suggest that Black
Body Image in People of African Descent 205
men may not use body figure as a criterion for dating a woman, it is likely that body size is a
factor in that decision, but is of less importance than other factors in determining potential
partners. In addition, Webb and colleagues findings may be related to their methodology: the
figure rating scale that was used showed men nine drawings of women varying in one
dimension (body fat) on a continuum from very thin to heavier/obese. It is possible that
although Black men do not place as much importance on low body fat in women, they value a
curvy, feminine figure more and, thus, may be more accepting of women with more body fat
overall to achieve that body shape. Because the authors did not use a measure that varied
womens waist-to-hip ratio in addition to one that varied body fat, it is impossible to draw any
conclusions regarding the relative importance that womens shape and overall size play for
Black men.
Not only are Black men are more accepting of larger women (Jones et al., 2007; Webb et
al., 2004), data also suggest that Black women are more accepting of a broader range of body
size for themselves. For example, after for controlling for income, age, and marital status, the
percent of variance in body dissatisfaction scores accounted for by BMI was significantly
greater in White women (21%) than Black women (11%), supporting the idea that weight is a
less important predictor of body satisfaction in Black women than it is for White women
(Caldwell, Brownell, & Wilfley, 1997). Cultural preferences may guide the more flexible
body size and shape preferences of Black men and women. It is also possible that Black
mens preferences for larger figures may influence Black womens ideal figures, as women
who conform to the ideals of those they wish to attract would be more likely to be successful
in finding a partner. It is likely that both of these are true; however, research has not
compared the importance that Black women place on cultural values to potential partners
body size and shape preferences when determining their ideal body shape and size.
Although a great deal of research has suggested that Black men and women have better
body image, some studies have not found significant differences. For example, after
controlling for income, marital status, and BMI, Black and White Consumer Reports survey
respondents did not significantly differ on measures of body dissatisfaction, current-ideal
discrepancy, and self-esteem (Caldwell et al., 1997). These data suggest that other researchers
might have been confounding variables such as socioeconomic status (SES) with race, and
that differences in body satisfaction, self-esteem, and discrepancies between current and ideal
figures may be related to SES rather than race.
Research conducted in Black South African schoolgirls found that two thirds of the girls
perceived fatness as a sign of happiness and wealth (Puoane, Tsolekile, & Steyn, 2010).
About a third of the participants had mixed views regarding the advantages of fatness (Puoane
et al.). Three fourths of the girls associated thinness with ill health, most often with
HIV/AIDS and tuberculosis (Puoane et al.). Obese girls who thought obesity was preferable
cited reasons such as needing strength for engaging in sports and reporting that fat females
look more respectable (Puoane et al.). However, these girls also associated obesity with
difficulty finding clothing sizes and with chronic diseases such as hypertension and diabetes,
the reduced risk of which was given as an advantage of being thin (Puoane et al.).
Cross-cultural body image research conducted in 26 nations found that heavier bodies
were preferred in low-SES sites compared to high-SES sites in developing nations but not in
Westernized countries (Swami et al., 2010). The authors suggested that when SES differences
are absent or controlled, cross-cultural differences in body weight ideals are small if present
(Swami et al.). Additionally, participant age, BMI, and Western media exposure predicted
body weight ideals and BMI and Western media exposure significantly predicted body
dissatisfaction in women (Swami et al.).
THIN IDEAL INTERNALIZATION AND MEDIA INFLUENCE

There are many possible reasons for the differences that have been found in White and
Black individuals body image satisfaction and preferred body size. White women have
reported greater levels of thin-ideal internalization and stronger beliefs that thinness enhanced
their romantic desirability than Black women (Vaughan, Sacco, & Beckstead, 2008). In
addition, the White women in this sample reported higher dietary restriction and had lower
BMIs, both of which were significantly predicted by thin-ideal internalization and belief that
thinness confers romantic desirability (Vaughan et al.). In a community sample of White,
Black, Asian, and Latina women in Los Angeles, women of all ethnicities who were more
acculturated to the dominant culture were more likely to suffer from eating problems
(Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000). It is possible that Black women
who have not internalized the Western beauty ideal of thinness may not strive to conform to
the difficult-to-attain standards of beauty presented in the mainstream media and may have
better body image and restrict their eating less as a result.
Recent data regarding the effects of the media on Black women suggest that they may not
be as susceptible as White women are to internalizing mainstream beauty ideals. Festingers
(1954) social comparison theory provides an explanation as to why increased exposure to an
unreachable body ideal may not decrease body-esteem in Black women. According to social
comparison theory, when the attractiveness of a particular group (e.g., mainstream portrayals
of beauty in the media) is particularly strong (i.e., the individual is strongly invested in that
body ideal), but the individual differs markedly from the group in a specific ability (e.g., she
is unable to reach the body ideal), a situation will be created in which the individuals values
and strivings are quite out of line. In White women, the difficult-to-attain media images of
skinny, tall, blonde, blue-eyed women might be internalized because White women may be
similar in a number of ways to the media images they see. On the other hand, when a Black
woman views the same media images, she may not identify with the White beauty ideal
because there are already so many physical differences that are impossible to change (i.e.,
skin color, hair texture, facial features), that there is no reason to try to attain that physically
impossible beauty ideal. Instead, Black women may compare themselves to Black women in
the media.
Research supports this theory. White women reported higher body dissatisfaction after
viewing slides of White media ideals and reported lower body dissatisfaction after viewing
pictures of normal-weight White women (DeBraganza & Hausenblas, 2008). In comparison,
Black womens body dissatisfaction did not change after viewing slides of normal-weight
White women or slides representing the White beauty ideal (DeBraganza & Hausenblas). De
Braganza and Hausenblas cited a participants comment: These women were too skinny.
Also the women were White, so they dont represent Black beauty which is different from
what is appealing to White women. Frisby (2004) also reported similar results in a sample of
Black women: exposure to images of thin-ideal White models was not related to lower
evaluations of the self, regardless of the participants initial level of body esteem. On the
other hand, Black women with low body esteem who were exposed to Black ideal images did
report decreased self-satisfaction (Frisby).
Schooler, Ward, Merriwether, and Caruthers (2004) expanded on this research by
surveying Black and White female undergraduates about the number of hours spent watching
mainstream television and shows with predominantly Black casts when they were in high
school (specific programs were also queried to help increase accuracy of retrospective recall
of television watching). They found significant associations between greater exposure to
mainstream programming during adolescence and poorer body image in college in White
participants, but not in Black participants with the same levels of mainstream media exposure
(Schooler et al.). Although not completely intuitive, the effects of watching television shows
with predominantly Black casts had the opposite effect: exposure to Black programs in high
school did not effect the body image of White women in college (as would be expected), but
increased exposure to Black programs in high school was associated with higher body image
in college in Black participants (Schooler et al.). These data support the notion that Black
women reject comparisons with White characters and may instead compare themselves to
Black characters, whereas White women compare themselves to the White characters they
watch.
The authors speculated as to why watching television programs oriented toward Black
viewers might have a positive effect on body image in Black women rather than a negative
outcome as is found in White women exposed to White thin-ideal actresses. Schooler and
colleagues (2004) suggested that either the programs and messages about appearance that are
in mainstream TV differ from those in Black-oriented programming, or the mechanism by
which White and Black women compare themselves to media images differs. Both of these
are likely to be true. Television programs oriented toward Black audiences typically feature
actresses whose body types cover a broader range than actresses in predominantly White casts
(Tirodkar & Jain, 2003). Also, given the historical absence of Black women in the media,
simply presenting Black female characters on TV may affirm the beauty of all Black women,
regardless of shape and size (Schooler et al.).
DISORDERED EATING
If Black women have better body image, as is suggested by much of the research, then it
follows that Black women should have lower levels of negative correlates of low body image
such as dietary restriction and eating disturbances than those reported in predominantly White
samples. There is a significant interaction between gender and ethnicity in dieting: Black
men, Black women, and White men diet infrequently, whereas White women are more likely
to diet (Aruguete et al., 2004). In a survey of college students, significantly fewer Black
women met DSM-III criteria for bulimia nervosa than White women (Gray, Ford, & Kelly,
1987). Black women in this sample were also significantly less likely to experience a sense of
fear and discouragement regarding food and weight control (Gray et al.).
In a community sample of middle-aged women, similar results were found: White
women experienced higher levels of eating disturbances after controlling for BMI than Black
women (Wilfley et al., 1996). Wilfley et al. found that similar factors such as social pressure
(e.g., comments or criticism made by a family member or significant other) and attitudes
about overweight predicted body dissatisfaction both in Black and White women. In a sample
of clinically depressed females in an inpatient psychiatric unit, healthy-weight, overweight,
and obese depressed Black women did not differ significantly on measures of self-esteem and
suicide risk (Palmer, 2003). On the other hand, depressed White women who were obese had
significantly lower self-esteem and increased suicide risk than depressed healthy-weight and
overweight White women (Palmer). Other research has found that expectancies about eating
and thinness moderate the relationship between ethnic identity and maladaptive eating
attitudes and behaviors in African American female college students (Henrickson, Crowther,
& Harrington, 2010). Among Black female students who expected that eating would manage
affect and thinness and restricting would lead to generalized life improvement, there was a
significant negative relationship between aspects of ethnic identity and maladaptive eating
attitudes and behaviors and a significant positive relationship between orientation to other
groups (most likely mainstream culture) and maladaptive eating attitudes and behavior
(Henrickson et al.).
However, there have been some incompatible results regarding whether or not significant
differences in eating disturbance rates exist. A sample of youths actually found higher rates of
binge eating among African American boys (26%) than African American girls (17%), White
boys (19%), and White girls (18%; Johnson, Rohan, & Kirk, 2002). In a meta-analysis of 18
studies (N = 26,271) reporting rates of eating disturbances in Black and White women,
ONeill (2003) reported a small but significant overall relationship between ethnicity and
eating disturbances. There was a small but significant effect showing that Black women have
fewer eating disturbances than White women; however, ONeill noted that it is difficult to
compare the studies due to the heterogeneity in dependent variables (e.g., drive for thinness,
bulimia symptomatology, binge eating disorder symptomatology, eating attitudes, etc.).
Notably, the meta-analysis did not yield significant differences in rates of bulimia nervosa or
binge eating disorder. On the other hand, Black women were significantly less likely to show
anorexia nervosa-like eating attitudes and behaviors (ONeill). Also, Black women with
similar scores as White women on a measure of drive for thinness showed lower rates of
eating disturbances (ONeill).
Examination of individuals seeking treatment for eating disorders at the University of
Minnesota in the past twenty years also revealed almost no anorexia-like disordered eating in
Black patients (Fernandes, Crow, Thuras, & Peterson, 2010). Additionally, Black patients had
higher body dissatisfaction than White patients, which contradicts other research. However,
these data may be a result of sampling bias, as this was a treatment-seeking sample. Black
individuals may be less likely to seek treatment for eating disorders and body image
dissatisfaction than White women because it is less culturally accepted and more stigmatized.
Thus, Black individuals suffering from disordered eating may wait until symptoms are more
severe before seeking treatment.
In a sample of Asian, Hispanic, Black, and White women with disordered eating, there
were not many differences in the presentation of eating disorder symptoms (Cachelin, Veisel,
Barzegarnazi, & Striegel-Moore, 2000). All groups were equally likely to report the key
behavioral symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder
(Cachelin et al.). The only differences found among participants of different ethnicities were
in specific purgative behaviors: Hispanic women were significantly more likely to use
diuretics and Black women were significantly more likely to use laxatives (Cachelin et al.).
CONCLUSION
Overall, it is likely that there is a small, but significant racial/ethnic difference in eating
disorder rates and types of eating disordered behavior (i.e., binge eating versus dietary
restriction, using laxatives versus diuretics as a compensatory behavior), but individual
studies may not have adequate power to detect the small effect sizes and differing results
across individual studies may result from sampling error, leading to discrepant findings. Data
suggest that at the same BMI as White women, Black women may be less likely to experience
negative side effects like body dissatisfaction (Tyler et al., 2009) and eating disorder
symptoms (ONeill, 2003; Wilfley et al., 1996), although there is some research that suggests
that SES may have been confounded with ethnicity in some of the research (Caldwell et al.,
1997). Altogether, BMI seems to play less of a role in Black womens self-esteem and
psychological well-being than has been found in White women (Caldwell et al.).
However, the preference for or acceptance of larger body sizes in Black men and women
may be a double-edged sword. On one hand, it seems to protect against body image
dissatisfaction, low self-esteem, low body-esteem, and disordered eating. On the other hand,
Black people are more likely to be overweight or obese and are also more likely to suffer
from many of the related chronic diseases (Brown, 2008; see Figure 1), although low SES
may be a significant contributor to the ethnic differences seen in overweight and obesity.
Note: CHD = coronary heart disease (which includes heart attack and angina pectoris); CVD =
cardiovascular disease (which includes coronary heart disease, stroke, high blood pressure,
atherosclerosis, and heart failure). Data on coronary heart disease, stroke, and type 2 diabetes were
only available for women. Data are from National Center for Health Statistics. Health, United
States, 2007 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2007.
Figure 1. Overweight and obesity and rates of chronic diseases in Black and White men and women.
While body image dissatisfaction is not a good thing by any means, it may have some
beneficial indirect effects, at least in the Black community where a larger female figure is
often viewed positively. For example, in a sample of overweight Black girls aged 11-17,
Stern and colleagues (2006) found that positive body image and self-esteem predicted less
willingness to engage in healthy behaviors that would promote weight loss, such as exercising
and eating less. The Black girls who experienced weight-related teasing were more likely to
be worried about their weight, to admit that their weight was a health problem, and to be
interested in the weight-loss intervention (Stern et al.). Thus, it seems that although being
concerned about ones weight may have a lot of negative consequences, it may aid in weight
loss efforts for those who need it, at least in certain populations. Vaughan and colleagues
(2008) data support this idea. In their sample, Black women had a significantly higher
average BMI than White women, as has been reported elsewhere (e.g., Brown, 2008). Using
SEM, they found that at higher levels of dietary restriction, the premium placed on thinness in
evaluating attractiveness and romantic desirability partially mediated the relationship between
ethnicity and maintenance of a lower BMI, which could be considered a positive health
outcome.
There are a number of directions for future research. First, the research in body image in
men is notably scarce. Some research has found no differences in body image between Black
and White men (Cachelin, Rebeck, Chung, & Pelayo, 2002; Chandler, Abood, Lee,
Cleveland, & Daly, 1994; Demarest & Allen, 2000) and some have found that Black males
have significantly better body image (Ricciardelli, McCabe, Williams, & Thompson, 2007;
Smith et al., 1999; Story, French, Resnick, & Blum, 1995). The incongruent findings may be
explained by sampling error, inadequate power, and whether the assessment measures used
were appropriate for the populations being studied.
Second, research needs to pay more attention to assessing body fat preferences and body
shape preferences by using figure rating scales that vary both body fat and waist-to-hip ratio
when assessing female figures and body fat and muscularity when assessing male figures.
Previously, most studies assessing current and ideal body discrepancies have only assessed
preferences for female figures based on a continuum of thin to fat because, in predominantly
White samples, body fat accounts for the most variance (70%) in attractiveness ratings,
compared to the variance accounted for by waist-to-hip ratio (2%; Tove, Maisey, Emery, &
Cornelissen, 1999). Whether or not this relationship would be similar in Black individuals
attractiveness ratings of female figures is unclear.
Third, greater attention needs to be paid to determinants of body image and body esteem
in people of African descent. Although some studies looked at how body image relates to
acculturation or ethnic identity, and some have even included other aspects of body image,
such as skin tone (Keith & Herring, 1991; Thompson & Keith, 2001), research needs to
examine more aspects that determine body image, such as functional variables like strength,
success in sports, etc., as well as other aspects of appearance such as hair, nails, skin tone,
jewelry, clothing, etc. in Black people. Last, more attention needs to be paid to possible
mediators and moderators of body image in Black populations, such as the effects of racism.
It is possible that exposure to racism partially mediates the relationship between race and
body image satisfaction. Ethnic identity and acculturation into the dominant culture have been
studied but more research that includes these variables in proposed models of body image and
thin-ideal internalization is needed.
There are data showing that the internalization of the thin-ideal can lead to disordered
eating, low body-esteem, body dissatisfaction, and low self-esteem, but it is possible that
striving to be slender might help women maintain a healthy BMI (Vaughan et al., 2008),
which is difficult for most people to do in the current obesigenic environment without
considerable, consistent effort. Further research needs to investigate ways to increase health
behaviors (such as decreasing portion sizes, eating nutritious foods, and increasing exercise)
in Black individuals without trying to inculcate an overly thin beauty ideal that may be
detrimental to physical and psychological well-being. To do this, an emphasis on increasing
health behavior and health risks of overweight and obesity and a de-emphasis on appearance
may be most beneficial.
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Chapter 12
LOW SES CHILDRENS BMI SCORES AND THEIR

PERCEIVED AND IDEAL BODY IMAGES:
INTERVENTION IMPLICATIONS
Simone Pettigrew,1*Melanie Pescud2 and

Robert J. Donovan
1
University of Western Australia, Perth, Australia
2
University of Western Australia, Perth, Australia
3
Curtin University of Technology, Perth, Australia
ABSTRACT
BMI cut-offs were used in conjunction with the Childrens Body Image Scale to
provide a comparison between actual BMI and perceived and ideal body images among
90 low socioeconomic children aged seven to 10 years. A third of the sample was
classified as overweight or obese, with a higher incidence among boys (38% versus 28%
for girls). Two-thirds underestimated their current body size and only around 5%
considered themselves overweight or obese. Just over 70% selected an underweight ideal
body size. Intervention developers thus face the dual challenge of providing children and
their families with the information and skills they need to prevent childhood obesity
while addressing a lack of awareness of actual body weight among children that is
combined with an unrealistic ideal body size preference. This task is complicated by the
need to minimise weight concerns that can result in eating disorders. The results suggest
the need for a family-based approach that targets parents of young children to increase
awareness of healthy body sizes and lifestyle behaviours before children have become
*
Corresponding author:
Professor Simone Pettigrew
University of Western Australia
M261, 35 Stirling Highway
Crawley WA 6009
Australia
Ph: +61 8 6488 1437
Fax: +61 8 6488 1072
simone.pettigrew@uwa.edu.au
216 Simone Pettigrew, Melanie Pescud and Robert J. Donovan
overweight, formed inaccurate weight-related beliefs, and/or become dissatisfied with

their bodies.
INTRODUCTION
Childhood obesity has reached epidemic proportions in many countries, including
Australia. In Western Australia, the incidence of overweight and obesity has trebled in the last
20 years (Hands et al., 2004). There is a danger that as childhood obesity rates escalate,
overweight will become normalised which will prevent health workers, parents, and children
from recognising the condition (Spurrier et al., 2006). Previous studies have found that many
parents of overweight and obese children consider their children to be of normal weight
(Crawford et al. 2006; Eckstein et al., 2006; Huang et al., 2007; Maynard et al., 2003).
Similarly, many overweight and obese children perceive themselves to be normal or even
underweight (ODea and Caputi, 2001; Truby and Paxton, 2002). Health workers have also
been found to be unable to make consistently accurate weight assessments (Caccamese et al.,
2002; Gerner et al., 2006; Spurrier et al., 2006). As recognition of abnormality is an
important preliminary stage in the obesity treatment process (De Onis, 2004), it is critical for
families and practitioners to be aware of normal versus abnormal levels of adiposity to ensure
appropriate preventive and corrective strategies are initiated and maintained.
There are two primary mechanisms via which a lack of recognition of the physical
manifestation of childhood obesity could reduce the likelihood of behavioural change within
families. In the first instance, where parents fail to appreciate childrens weight problems they
may remain unaware of the need to make modifications to their childrens diet and activity
levels or actively educate them about the characteristics and benefits of a healthy lifestyle.
Second, children who consider themselves to be of normal weight may be less motivated to
comply with parents or health professionals attempts to change their lifestyles. It is also
possible that these children would make non-ideal food choices in environments lacking
parental supervision, such as school canteens.
Body image is a useful theoretical construct for examining individuals ability to
accurately assess their weight status (Grogan, 2006). Much work in the area of body image
has focused on the relationship between poor body image and negative outcomes such as
psychological distress and eating disorders (Cohane and Pope, 2001; Sands et al., 1997).
However, the construct may be also useful for investigating the possibility that inaccurate
body image assessment prevents the recognition of overweight in children. The present study
used Cole et al.s (2000, 2007) body mass index (BMI) cut-offs for weight status in
conjunction with Truby and Paxtons (2002) Childrens Body Image Scale (CBIS) to provide
a comparison between actual BMI and perceived and ideal body images among children aged
seven to 10 years. The study was innovative in the use of new underweight cut-offs, the
alignment of new and existing BMI cut-offs with a body image scale, and the focus on low
SES children of low socioeconomic status (SES). The results are discussed in terms of their
implications for family nutrition interventions that aim to prevent and reduce childhood
obesity by facilitating more accurate body size assessments.
Low SES Childrens BMI Scores and their Perceived and Ideal Body Images 217
METHOD
Sample
Students in years 3 to 5 (aged seven to 10 years) attending a low SES school in Perth,
Western Australia participated in the study. SES was determined by consulting the Australian
Bureau of Statistics Socio-Economic Indexes for Areas index. A low SES school was
selected as childhood obesity is disproportionately higher among the socioeconomically
disadvantaged in Australia (ODea, 2003; Wake et al., 2007), making this group a priority for
prevention and treatment.
Procedure
The children completed a questionnaire and three weeks later had their BMI
measurements taken. Both data collection phases occurred during normal school hours. Due
to the age of the participants, the questionnaire was kept relatively short and the questions
were read aloud to overcome a lack of reading skills in some children. The questionnaire
items included basic demographics (age, gender) and questions relating to the childrens
consumption of fruit and vegetables and their favourite foods. The questionnaire concluded
with the CBIS instrument featuring both boys and girls images (see Figure 1). The children
were asked to draw a circle around the image they considered to be most like their actual
body size and to place a cross beside the image that best reflected how they would like to
look. While the images were presented in the questionnaire as they appear on the CBIS with
alphabetical titles (A to G), analyses were performed by converting to numerical titles and
using these as interval data (as per Tiggemann and Wilson-Barrett, 1998; Truby and Paxton,
2002).
During the anthropometric measurements, two children at a time were taken into a large
room where three data collectors took their weight and height measurements. The children
engaged in short activities while having their anthropometric measurements taken. These
activities were designed to put them at ease and to divert their attention away from the other
child in the room. While having their weight measured in 0.5kg intervals on digital scales, the
children were directed to look at a picture and count the number of items shown. This drew
their attention to the head-height picture and away from the weight reading visible on the
scales. While having their height measured in 0.1cm intervals on a stadiometer, children were
asked to look at a series of stickers and choose which one they would like to take as a token
of appreciation for their involvement in the study. This task had the added benefit of bringing
their heads to an appropriate angle for correct measurement with the stadiometer and
therefore reduced the amount of manual manipulation required to adjust their heads to the
Frankfurt plane.
Scale Measures
Truby and Paxtons (2002) CBIS was selected for application in the present study over
other childrens body image scales because it is comprised of morphed composite
photographs that more closely resemble real children than do the silhouettes used in other
scales. Truby and Paxton created the images by morphing pictures of children who exhibited
a range of BMI scores across the 1977 US National Centre for Health Statistics BMI
percentiles. The resulting scale is comprised of seven images of boys and seven images of
girls that represent BMI scores ranging from 13.0 (underweight) to 29.0 (obese) (see Figure
1). As has typically been the case in research using other scales, the CBIS correlation between
actual BMI and perceived body size was found by Truby and Paxton to be lower for boys
(r=.35) than for girls (r=.60). This outcome has been attributed in the past to the failure of
image instruments to provide response options that differ in muscularity as well as adiposity
(Cohane and Pope, 2001; ODea and Caputi, 2001). Truby and Paxton additionally suggest
that boys may be less sensitised to weight issues than girls, rendering them less competent in
their appraisal of varying body shapes. Cole et al.s BMI cut-offs were employed as they
provide cut-offs for all four weight categories and they have been found to be more relevant
than other BMI categorisations for non-US populations (Flegal et al., 2001; Abrantes,
Lamounier, and Colosimo 2003).
RESULTS
Due to the use of an opt-out recruitment method (as approved by a University Ethics
Committee), the response rate was 100% of children present on the data collection days. A
total of 112 children had their BMI measurements taken on at least one occasion and 110
completed the questionnaire. Complete data sets were obtained from 90 children and
subsequent analyses included only the data from these 90 children. Boys constituted 52% of
the sample and most participants were eight or nine years of age (81%). Table 1 provides a
summary of age and gender characteristics and average BMI scores of the sample.
Table 1. Participant characteristics
Age Boys Girls Total
n Av. BMI n Av. BMI N

7 3 16.94 0 N/A 3
8 19 17.14 24 17.75 43
9 20 18.67 10 17.22 30
10 5 22.78 9 17.97 14
Total 47 (52%) 18.38 43 (48%) 17.67 90 (100%)
Using Cole et al.s BMI cut-offs, the childrens BMI measurements were used to classify
them as underweight, normal, overweight, or obese. Table 2 shows the distribution of the
sample across these weight categories. According to Cole et al.s cut-offs, nearly 6% of the
children sampled were underweight, 61% were normal weight, 23% were overweight, and
10% were obese. Combining the overweight and obese categories, 38% of boys and 28% of
girls were larger for their age than is considered healthy.
Table 2. Distribution of BMI scores by weight category and gender (%)
Weight Category* Boys Girls Total

Underweight 8.5 2.3 5.6
Normal 53.2 69.8 61.1
Overweight 29.8 16.3 23.3
Obese 8.5 11.6 10.0
Total 100 100 100
*As per Cole et al.s (2000, 2007) BMI cut-offs.
Matching students CBIS selections to their Cole et al. weight categories, Table 3 shows
the distribution of participants perceived and ideal body image selections and their actual
BMI status across these weight categories. Among the boys there was a significant positive
association between age and BMI [F = 6.01, df = 3, p = 0.002] and age and perceived body
size [F = 2.72, df = 3, p = 0.056], but not between age and ideal body size. No significant age
associations were evident among the girls.
There is a clear discrepancy between the actual and perceived distributions, with a skew
away from the overweight and obese categories and towards the underweight category. Two-
thirds (67%) underestimated their current body size, with boys somewhat more likely to
underestimate their body size (72%) than girls (61%). Participants ideal weight showed an
even greater skew towards the underweight category, with 71% expressing a preference for a
clinically underweight ideal body size. More girls (77%) than boys (66%) expressed this
preference.
Table 3. Distribution of actual, perceived, and ideal scores by weight category and
gender (%)
Weight Boys Girls Total

Category*
Actual Perceived Ideal Actual Perceived Ideal Actual Perceived Ideal
Underweight 8.5 42.6 66.0 2.3 30.2 76.7 5.6 36.7 71.2
Normal 53.2 53.2 27.7 69.8 62.8 21.0 61.1 57.8 24.4
Overweight 29.8 2.1 0.0 16.3 0.0 0.0 23.3 1.1 0.0
Obese 8.5 2.1 6.3 11.6 7.0 2.3 10.0 4.4 4.4
Total 100 100 100 100 100 100 100 100 100
*As per Cole et al.s (2000, 2007) BMI cut-offs.
Figure 1 shows the mean ideal and perceived body images selected by participants on the
CBIS and their mean body image as per average BMI scores. There is a considerable gap
between participants actual body sizes and their perceived and ideal body sizes: 72% of boys
and 63% of girls had two or more images between their actual and ideal body sizes, and 30%
of girls and 17% of boys had two or more images between their perceived and ideal body
sizes.
Scale figures reproduced with permission.
Figure 1. Average BMI, perceived image, and ideal image by gender.
The gap between perceived and ideal body size, known as the index of dissatisfaction
(IoD), has been the focus of numerous studies involving both children and adults (e.g.,
Kostanski and Gullone, 1998; Sands et al., 1997). By comparison, the gaps between actual
and perceived body size and actual and ideal size have received little attention. The gap
between actual BMI and perceived size is named here the index of error (IoE), and was
calculated by subtracting the number representing the selected perceived image on the CBIS
scale from the numerical position on the scale that was aligned with the childs BMI score.
The gap between actual BMI and ideal body size is named here the index of aspiration (IoA)
and was calculated by subtracting the number representing the selected ideal image on the
CBIS scale from the numerical position on the scale that was aligned with the childs BMI
score (see Table 4). Of note is that the IoD and IoA were on average larger among the girls
and the IoE was larger among the boys, although only the gender difference in IoD was
statistically significant [F = 5.14, df = 1, p = .03].
Table 4. Mean actual, perceived, and ideal scores by gender
N Actual Corresponding Perceived Ideal IoD IoE IoA

BMI CBIS image image image
Boys 47 18.38 4.06 2.74 2.23 0.51 1.32 1.83

Girls 43 17.68 4.05 3.09 1.93 1.16 0.96 2.12
DISCUSSION
A third of children participating in this study were overweight or obese. This is somewhat
higher than indicated in previous Australian studies but consistent with data that obesity is
related to lower SES status. Only around 5% of participants recognised themselves (or at least
admitted recognising themselves) as overweight or obese as measured by the CBIS. This
outcome supports previous work indicating that many overweight children are unaware of
their weight status (e.g., ODea and Caputi, 2001; Truby and Paxton, 2002). At the same
time, a majority of participants selected an ideal body size that was clinically underweight
and substantially smaller than their actual body size. While these results are interpreted with
caution because of the limited sample size, they suggest that children of this age lack the
knowledge and/or skill to recognise the physical manifestation of the various weight
categories. This is likely to reduce their ability to accurately assess their own weight status
and to appreciate the need for behavioural change.
The larger IoD found amongst girls in this study reflects the findings of previous research
and offers further support for the suggestion that females in Western countries experience a
normative discontent with their bodies (Silberstein et al., 1988). This is particularly
worrisome when understood in the context of the girls larger IoA scores that make the
attainment of their ideal body shape almost impossible as well as inappropriate for their
health. The tendency for boys to exhibit a larger IoE may be partly attributable to the
limitations of image scales that focus entirely on adiposity without consideration of
muscularity, but may also suggest a general lower level of interest in weight issues as
suggested by Truby and Paxton (2002).
Intervention Implications
The three indices used in this study (IoD, IoE and IoA) provide insight into the
difficulties associated with addressing the childhood obesity crisis. The IoE demonstrates the
extent to which many children participating in the study were oblivious to their true weight
status; the IoD shows that even while underestimating their weight, many of the children were
dissatisfied with their current body size; and the IoA highlights the large gap between the
childrens actual and ideal body sizes.
The extent of overweight and obesity in the sample and the inability of the study
participants to accurately assess their own body size and select appropriate aspirational body
shapes indicate that prevention interventions need to start earlier in life than has generally
been recognised. By their pre-adolescent years, many children are already experiencing
weight problems that will predispose them to obesity in later childhood (OBrien et al., 2007)
and adulthood (Guo et al., 2002). It appears that in order to access children before many have
become overweight or obese, formed inaccurate weight-related beliefs, and/or become
dissatisfied with their own bodies, it is necessary to target children younger than seven or
eight years of age. This approach has been suggested by some researchers (Kostanski and
Gullone, 1998; Smolak, 2004), but is not readily apparent in previous interventions.
A difficulty associated with making children the focus of obesity prevention programs is
that sensitising children to weight issues can result in weight concerns that have the potential
to actually increase the risk of obesity by promoting unhealthy behaviours such as binge
eating (Haines and Neumark-Sztainer, 2006). Weight concerns can also discourage
participation in physical activity and thus exacerbate weight problems (ODea, 2005). These
unintended consequences have resulted in a recommended emphasis on healthy lifestyles
rather than explicitly addressing overweight (ODea, 2005). However, the IoE results
discussed above indicate that children may experience considerably greater difficulty
assessing their own adiposity than do adults (Giskes and Siu, 2008). This may result in them
paying little attention to healthy eating and healthy lifestyle messages due to a perceived lack
of personal salience. This leaves the dilemma of how to instigate behavioural change among
these children without triggering counter-productive weight concerns.
There is a growing recognition that interventions need to be family-based rather than just
focused on the child (Catford 2003; Golan and Weizman, 2001; Livingstone, McCaffrey, and
Rennie 2006; Zwiauer, 2000). Parents are likely to have a greater ability to learn and apply
weight assessment principles and can introduce lifestyle changes at the household level. One
strategy may be to educate parents about the appearance of healthy weight in children to
empower them to recognise and address weight problems in their children. Such education
would also need to include information relating to the behaviours associated with a healthy
lifestyle and ways of positively encouraging children to adopt these behaviours without
triggering body dissatisfaction. Such a strategy is supported by those who advocate the
inclusion of parents in a holistic approach to the prevention of obesity and eating disorders on
the basis of the shared risk factors for these two conditions (Haines and Neumark-Sztainer,
2006; Neumark-Sztainer, 2003). It is also similar to the recommendations relating to the
provision of BMI screening information to parents and the resulting need to encourage
appropriate responses among those learning that their children are overweight (De Onis,
2004; Ikeda et al., 2006).
An adult-centred approach is supported by the alarming IoA outcome that the majority of
children aspired to a clinically underweight body size. Forces external to the child determine
social perceptions of ideal body size, in particular the depiction and framing of body sizes in
the celebrity, fashion, news, and entertainment media (Swinburn, Egger, and Raza, 1999), and
children require assistance from their parents and other adults to resist this social
conditioning. The present results indicate the need to substantially increase efforts to address
these macro influences at a public policy level while also assisting parents to normalise
healthy body sizes for their children.
To conclude, intervention developers face the dual challenge of providing children and
their families with the information and skills they require to prevent and treat child obesity
while addressing a lack of awareness of actual body weight among children that is combined
with an unrealistic ideal body preference. This task is complicated by the need to tread
carefully to minimise counter-productive weight concerns that can result in disordered eating.
The results of this study suggest that intervention components targeting children should avoid
references to size and comprehensive interventions should adopt an all-of-family approach
that focuses on weight-related behaviours such as healthy food choices and increasing
physical activity. Societal-level initiatives that seek to normalise health weight and address
the pervasive underweight ideal would also appear warranted.
ACKNOWLEDGMENT
This project was funded by Healthway (the Western Australian Health Promotion
Foundation) (#16187).
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In: Body Image: Perceptions, Interpretations and Attitudes ISBN: 978-1-61761-992-2
Editors: Sophia B. Greene 2011 Nova Science Publishers, Inc.
Chapter 13
THEORETICAL AND METHODOLOGICAL

CONSIDERATIONS IN ASSESSING BODY IMAGE
AMONG CHILDREN AND ADOLESCENTS
Margaret Lawler and Elizabeth Nixon

School of Psychology and Childrens Research Centre,
Trinity College Dublin, Ireland
ABSTRACT
Body image dissatisfaction, a prevalent concern among children and adolescents, has
been identified as a significant risk factor in the onset of eating pathology, depression and
low self-esteem (Levine & Smolak, 2002; Stice & Bearman, 2001; Stice, Presnell, &
Spangler, 2002). Given the negative implications of body image dissatisfaction, it is
important to examine how body image is currently conceptualized and measured. This
chapter proposes to explore theoretical and methodological issues underpinning the
assessment of body image dissatisfaction among children and adolescents. Careful
consideration of the assessment of body image dissatisfaction is further warranted in light
of emerging literature which highlights important gender differences in body appearance
concerns. While an ultra-thin body ideal is emphasized for females, the male appearance
ideal endorses a muscular physique characterised by broad shoulders and a well
developed chest. As such, girls typically demonstrate a drive for thinness, while boys
endorse a drive for muscularity. Empirical findings support this position, demonstrating
that girls are most satisfied with their bodies at below average levels of adiposity, with
dissatisfaction increasing with increased body mass. For boys however, body
dissatisfaction is reflected in a desire among some to lose weight, and a desire among
others to gain weight and become more muscular (McCabe & Ricciardelli, 2004). Such
gendered body image patterns have important implications for the assessment of body
image dissatisfaction. Indeed, concerns have been raised that commonly used measures
of body image dissatisfaction solely address ones desire to be smaller or thinner, which
is a predominantly female concern. Specifically, it has been argued that the figural rating
scales may produce a conceptual bias by manipulating adiposity only, therefore
confounding body mass with muscularity. This may be of theoretical consequence for
males who aspire to a muscular ideal. Questionnaire measures have also been criticized
due to their failure to identify the direction of body discontent (desire to be bigger versus
228 Margaret Lawler and Elizabeth Nixon
smaller), which may lead to the underestimation of body dissatisfaction among males. In
light of these important gendered patterns, this chapter will review the conceptual
frameworks and strengths and limitations of existing methods of assessing body
dissatisfaction among children and adolescents.
INTRODUCTION
Body image refers to the psychological experience of embodiment, especially but not
exclusively ones physical appearance. It is a multi-dimensional construct, encompassing
body-related self-perceptions and self-attitudes, including thoughts, feelings and behavior
(Cash & Pruzinski, 2002; Thompson, Heinberg, Altabe & Tantlefff-Dunn, 1999). Body image
evaluation or how satisfied one is with ones body is probably the most commonly measured
element of body image in children (Muth & Cash, 1997). Body image evaluation is
contingent upon the child being able to assess his/her body, having an internalized ideal with
which to compare ones own body and being capable of making a comparison (Smolak,
2004).
The prevalence of body image dissatisfaction among children and young people indicates
that children are capable of comparing their body image to that of an internalized ideal from a
young age. For girls, body image concerns revolve around body size and specifically fears
about being or becoming overweight. Girls as young as five years old report dissatisfaction
with their bodies and display knowledge about dieting (Lowes & Tiggemann, 2003;
Abramovitz & Birch, 2000; Davison, Markey & Birch, 2000). Prevalence of body size
dissatisfaction among girls increases steadily with age. Studies of pre-adolescent girls suggest
that somewhere between 40% and 60% of girls chose an ideal figure that is smaller than their
current figure (Lowes & Tiggeman, 2003; McCabe & Ricciardelli, 2003) and these
proportions rise to over 70% among studies of adolescent girls (Tiggemann & Pennington,
1990; Grigg, Bowman & Redman, 1996).
In general, much less research has considered prevalence of body image concerns among
boys and little research has been concerned with the body image satisfaction of boys younger
than 6 years. Spitzer, Henderson and Zivian (1999) found that the preference for a large and
muscular ideal among boys develops between the ages of 6 and 7 years. A recent review of
studies documenting the prevalence of body image concerns among pre-adolescent boys
concluded that between 27% and 47% of boys desired a thinner body size, while between
15% and 44% of boys desired a larger body size (Ricciardelli, McCabe, Mussap & Holt,
2009). In terms of body dissatisfaction among boys during adolescence, an early review of
research reported that approximately one-third of boys are dissatisfied with their weight
(Moore, 1993). However, this research did not consider whether boys desired larger or
smaller body sizes. Nowak and colleagues (1996) reported that 27% of the adolescent boys
wanted to lose weight, while Furnhan and Calnan (1998) reported that about two-thirds of
boys were dissatisfied with their bodies, with about half desiring weight gain and half
desiring weight loss. However it was not clear whether the desire to gain weight referred to
increased fat or increased muscle. Thus for boys, both weight and muscularity concerns
represent distinct pathways to body dissatisfaction.
Overall, this research suggests that from the time children enter formal schooling they
have already internalized gender-specific appearance ideals and are aware of how their own
Theoretical and Methodological Considerations in Assessing Body Image 229
bodies compare with these ideals. Body dissatisfaction in girls is underpinned by a Drive for
Thinness while body dissatisfaction in boys is underpinned primarily by a Drive for
Muscularity but also by a Drive for Thinness among a minority of boys. McCabe and
Ricciardelli (2004) caution that studies documenting higher levels of body dissatisfaction
among girls than boys often focus upon the desire to be smaller or thinner, and neglect
questions about gaining weight or building muscle. Failing to take account of the differing
ideals to which boys and girls aspire may have resulted in an underestimation of the extent
and nature of body dissatisfaction among boys. Ricciardelli and McCabe (2007) have
concluded that combining boys who are concerned about being too fat with boys who worry
about not being muscular enough yields a proportion of adolescent boys who are body
dissatisfied that is comparable to the proportion of adolescent girls who are body dissatisfied.
The extent of body image dissatisfaction among boys and girls is of concern. High levels
of body dissatisfaction are associated with poor self-esteem and depression, anxiety, fear of
negative evaluation and obsessive-compulsive tendencies (Stice & Bearman, 2001; Levine &
Smolak, 2002). Furthermore, among teenage girls, body image dissatisfaction has emerged as
key predictor of a perceived need to be thinner and actions of dieting, purging and other
eating problems across adolescence and into adulthood (Neumark-Sztainer, Paxton, Hannon,
Haines & Story, 2006). Similarly, Keel and colleagues found that poor body image was a
strong predictor of disordered eating among adolescent boys (Keel, Fulkerson & Leon, 1997;
Keel, Klump, Leon & Fulkerson, 1998). Boys whose body dissatisfaction revolved around
muscularity concerns are more likely to use food supplements and steroids (Smolak, Murnen
& Thompson, 2005).
In light of the prevalence of body image dissatisfaction and its association with a range of
negative outcomes, including the onset of eating pathology, depression and low self-esteem,
the appropriate measurement of body image dissatisfaction among children and adolescents is
of critical importance. This chapter provides an overview and evaluation of the measures that
have been developed to assess body image concerns among children and adolescents. Prior to
this, we present a brief overview of how body image is conceptualized.
CONCEPTUALIZATION OF BODY IMAGE

It is now recognized that body image is a multi-dimensional construct that encompasses
perceptual and attitudinal dimensions. The perceptual component involves judgment of ones
body size while the attitudinal component involves satisfaction or dissatisfaction with ones
body size or other physical attributes (Gardner, 2002). The attitudinal component incorporates
an evaluative dimension (discrepancies between the ideal and the real self, degree of
dissatisfaction) and an investment dimension (the importance of ones appearance to the sense
of self) (Cash & Pruzinsky, 2002).
The perceptual component of body image focuses primarily on distortions in perceived
body size and the majority of this research has studied perceptual distortions of body size
among individuals with eating disorders (Thompson & Gardner, 2002). Relatively little
research has examined this phenomenon among children, although some research has found
that experimental distortion of around 5% of ones body size on a video can be detected
among children as young as 6 years of age. Moreover, by age 14, children can reliably detect
a manipulated change of as little as 2% in their body size (Gardner, 2002). However,

Thompson and Gardner (2002) have highlighted that sensory sensitivity, or the ability to
detect correctly whether an image of the self has been distorted is a sensory factor, and is
distinct from non-sensory factors such as the persons tendency to over-report the body as too
thin or too wide. Thus, a person may correctly identify whether the image of his or her body
has been distorted or not but still display a bias in reporting that his or her body is too wide or
too thin. In other words, no sensory distortion may be present but the image still appears
distorted to the individual. This suggests that attitudes and affective responses may underpin a
tendency to perceive body size in a particular way, rather than any sensory deficit per se.
Indeed, the perceptual and attitudinal components of body image appear to function
independently and are not strongly related (Yanover & Thompson, 2009; Gardner, 2002).
The attitudinal component of body image is by far the most commonly assessed
dimension of body image. It has been conceptualized as consisting of four constructs: global
subjective satisfaction, affective responses to appearance, cognitive aspects of body image,
and behavioral patterns reflective of dissatisfaction with appearance (Thompson & Van den
Berg, 2002). Global subjective satisfaction refers to the extent of satisfaction with ones body
and appearance and can reflect satisfaction with weight, shaper or specific body sites.
Recently, the importance of satisfaction with functional dimensions of body image (what the
body can do) in addition to aesthetic aspects of the body (how the body looks) has been
emphasized (Abbott & Barber, 2010). However functional body image has been largely
overlooked in body image research.
Affective aspects of body image refer to emotions regarding body or appearance, while
cognitive aspects refer to beliefs about ones body and appearance, including the value or
degree of importance that individuals place upon different dimensions of their body and
appearance. These cognitive representations of body image have also been termed
appearance-related schemas (Cash, 1996). Originally, Markus (1977) proposed that self-
schemas are used to guide how we process information relating to the self. Based on this self-
schema theory, appearance schemas provide a cognitive representation of body image that
includes beliefs about the role of appearance, specifically the importance and meaning an
individual places on their appearance in their everyday life (Cash, 1996; Cash & Labarge,
1996). Appearance-related schemas require special consideration as the formation of these
schemas is believed to precede body dissatisfaction developmentally. In other words children
must firstly learn the importance of appearance before experiencing negative affective
consequences (Hargreaves & Tiggemann, 2002).
Appearance schemas are proposed to influence body image dissatisfaction by increasing
attention to, memory for, and interpretation of appearance-related material (Altabe &
Thompson, 1996; Hargreaves & Tiggemann, 2003). Although conceptually similar to
constructs such as internalization, appearance schemas reflect a broad range of physical
attributes and beliefs about the self, while internalization represents a particular appearance
domain (weight and shape) that may be attributed to either a self-schema (a guide for self-
evaluation) or social schema (belief about others) (Cash, 2005). It has been suggested that
appearance-related schemas guide the interpretation of socio-cultural messages regarding the
body and appearance. In other words, these schemas mediate between socio-cultural
influences (such as peers, the media) and an individuals body image (Clark & Tiggemann,
2007; Sinton & Birch, 2006; Hargreaves & Tiggemann, 2002).
The fourth dimension of the attitudinal component of body image relates to behavioral
indicators of the importance of ones appearance to the sense of self. These behaviors may
include techniques for controlling weight, building muscle or even avoidance of mirrors or
specific types of activities or clothes. Such behaviors are reflective of the investment made to
improve or maintain a particular aspect of ones body or appearance.
Cognitive aspects of body image reflecting the salience of body image to the persons
sense of self, as well as behaviors individuals perform to enhance or manage their looks
together constitute body-image investment which is conceptually distinct from evaluative
thoughts and feelings about body image (Cash & Szymanski, 1995). Derived from this multi-
dimensional conceptualization of body image, assessment of body image involves
considering both perceptual and attitudinal components of body image. Furthermore, within
the attitudinal component, one should consider evaluative body image, as well as body image
investment.
GENDER AND DEVELOPMENTAL CONSIDERATIONS IN ASSESSING

BODY IMAGE AMONG CHILDREN AND ADOLESCENTS
Assessment of body image among children and adolescents involves not only
consideration of the multi-dimensional nature of the construct, but also an appreciation of
how gender and developmental issues impact upon assessment. As indicated previously, body
image is a highly gendered phenomenon. From a young age, children are exposed to
culturally-defined images of physical ideals. The Western standard for female beauty has
been termed the thin ideal while males espouse a muscular ideal. To date, research has
been more concerned with childrens and adolescents desires to be thinner rather than
muscular (Smolak, 2004). In light of this, measures need to take account of potential concerns
salient to boys as well as girls. Thus, among boys and girls, it is essential to assess
dissatisfaction relating to degree of muscularity as well as degree of adiposity.
The choice of what measure to use to assess body image is also determined by childrens
age and developmental level. Limitations in young childrens attentional and memory
capacity, as well as their ability to think in abstract terms confine the length and complexity
of measures that can be employed (Trembley & Limbos, 2009). When measuring body image
among children and adolescents, it is essential that naturally occurring biological changes are
taken into account. For example, a figure scale depicting body shapes and sizes appropriate
for a child at 7 or 8 years of age is likely to be no longer appropriate for children of 11 or 12
years of age. During early adolescence, pubertal development results in increased weight and
levels of adiposity for females, thus moving them further away from the thinness ideal.
Indeed, Thompson and Chad (2000) found that the further along girls were in terms of
pubertal maturation, the higher their levels of body dissatisfaction. In contrast, puberty results
in boys bodies becoming more muscular; thus moving them closer to the masculine ideal.
Levine and Smolak (2002) concluded that the transition to puberty may exacerbate a
previously existing vulnerability to body image dissatisfaction. This suggests that the stage of
puberty and pubertal timing represent important backdrops to the assessment of body
dissatisfaction among adolescence. Aside from the physiological changes associated with
puberty, psychological and social transitions during early adolescence including emerging
sexuality, identity formation, gender role intensification and increased propensity towards
self-consciousness may heighten adolescents tendencies to compare their appearance with
those of their peer group (Dacey & Kenny, 1994). Thus intra-individual change as well as
contextual issues may render particular body image and appearance concerns more salient at
some periods in development than others.
ASSESSMENT OF BODY IMAGE

The assessment of body image dissatisfaction in children and adolescents presents
various challenges. As indicated previously, developmental changes in self and cognition
influence measurement choice and determine the suitability of available body dissatisfaction
methods (Tremblay & Limbos, 2009). Different instruments have been used to assess
different dimensions of body image among children and adolescents including figural rating
scales, questionnaires, implicit measures and perceptual measures.
Figural Rating Scales
Figural scales comprising silhouette or contour line drawings are commonly used to
evaluate attitudinal body dissatisfaction among children and adolescents. Participants are
presented with a series of male or female figures placed in ascending size order, ranging from
very thin to very obese, and asked to select the figure they think most closely approximates
their current size (actual self) and the figure they would most like to resemble (ideal self). The
discrepancy between ones current and ideal self is conceptualized as the degree of body
dissatisfaction (Thompson & Gray, 1995).
Depending on how the instructional format is delivered, figural rating scales can be used
to assess affective as well as cognitive components of body image dissatisfaction (Kostanski,
Fisher, & Gullone, 2004; Tiggemann, 1996). Accordingly, body ratings have been found to
significantly differ among individuals asked to select a figure they felt, as opposed to
thought approximated their current body most closely. Participants were found to rate
themselves as larger when asked to select a figure on the basis of how they felt (Thompson,
1991; Thompson & Dolce, 1989). Cognitive and affective factors therefore constitute
independent components of body dissatisfaction, which offer diverse information relevant to
overall body image (Tiggemann, 1996).
A potential limitation of figural (and other) body image instruments arises from their
initial development and validation with adult samples. While adult figures are typically stable
over time, childrens bodies undergo many changes transitioning through puberty (Yanover &
Thompson, 2009). Thus, simple modifications of adult measures for use with children and
adolescents, may fail to adequately tap body concerns specific to this developmental cohort.
In addition, many scales lack adequate psychometric information pertaining to children and
adolescents (Gardner, 2001). Due to these methodological shortcomings, Gardner and Brown
(2010) do not recommend using adult scales subsequently standardised with children to
assess body concerns among young people (e.g. Stunkard, Sorenson & Schusinger, 1983).
There are some scales available however, that have been developed specifically for
children. These include the Childrens Figure Rating Scale (FRS: Collins, 1991), a commonly
used measure, which comprises seven pictures of pre-adolescent children. In addition, the
Body Image Assessment - Children (Vernon-Guidry & Williamson, 1996) contains a separate
series of figures for children and preadolescents, enabling children to make relevant
comparisons with figures that resemble their own body. The scale demonstrates acceptable
test-retest reliability and convergent reliability with chEAT (Maloney, McGuire, & Daniels,
1988), a measure of eating disorder symptomology (Vernon-Guidry & Williamson, 1996).
Including different scales for children and preadolescents is recommended to facilitate
physical changes experienced during pubertal transitions (Yanover & Thompson, 2009).
The Childrens Body Image Scale (Truby & Paxton, 2002) provides an alternative
version of the traditional figural scale, presenting seven digital images in order of increasing
adiposity. Children can presumably identify with these life-like figures, making it a powerful
means of uncovering body image concerns pertinent to this population. By providing
photographic images of real children, this scale overcomes limitations associated with figural
drawings such as disproportionately sized features and unrealistic images. Moreover, images
are based on the standard percentile curves for body mass index in children as compared with
most commonly used figural scales, which are developed purely on the basis of artists
subjective impressions (Gardner, Jappe, & Gardner, 2009).
The primary methodological concern of rating scales however is that figures vary in term
of adiposity only, excluding assessment of muscularity. This is an important consideration
given that body dissatisfaction among boys is often split among those desiring weight loss
and those wanting to gain weight and become more muscular (McCabe & Ricciardelli, 2004).
Confounding body fat with muscularity thereby, reflects a conceptual bias of this measure
(Frederick et al, 2007). Moreover, by focusing simply on ones dissatisfaction with being too
large, the true extent of male dissatisfaction may have gone underreported.
In an attempt to address muscular concerns among males, Thompson and Tantleff (1992)
developed The Chest Rating Scale (CRS), which comprises five male figures that increase
incrementally in muscularity in the upper and mid-torso regions of the body. However, while
this technique takes account of muscularity appearance concerns it fails to address desire for
weight loss. Development of scales comprising figures that vary simultaneously in terms of
muscularity and body fat, similar to those in use among adult males (e.g. somatomorphic
index) are therefore recommended to evaluate body concerns specific to boys.
An additional issue requiring consideration is the manner in which discrepancy scores are
analyzed. Actual-ideal body discrepancy scores typically vary between positive and negative
values among males, reflecting a desire for smaller and larger body sizes respectively.
Therefore, reporting mean discrepancy scores may hide the true extent and severity of male
body image dissatisfaction (Kostanski, et al., 2004; Grogan, 2008). Future studies utilizing
this measure should ensure absolute values are reported to facilitate a greater understanding
of the nature of body dissatisfaction among adolescent and younger boys.
Although figural scales are subject to limitations they provide an extremely effective
means of gathering large-scale data in a cost effective-manner. Moreover, they provide a non-
intrusive means of body image assessment among children (Tremblay & Limbos, 2009). It
should be noted however, that a lack of evidence exists regarding the age at which childrens
body ratings and subsequently, the body dissatisfaction measure they represent, are deemed
reliable (Smolak, 2004). It is therefore, imperative that future research focuses on

standardizing figural scales of body dissatisfaction with this young population.
QUESTIONNAIRE MEASURES
Questionnaire measures provide a popular alternative or supplement to figural rating
scales. The Eating Disorders Inventory Body Dissatisfaction scale (EDI-BD; Garner,
Olmstead, & Polivy, 1983) is among the most frequently used measures of body
dissatisfaction in children and adolescents. Based on a likert scale, participants rate their
satisfaction with several body parts from the mid and lower torso (e.g. hips, thighs, buttocks).
Body dissatisfaction is determined by summing the individual responses. While the scale
assesses discontent with specific body parts, it fails to discriminate the direction of discontent
(also a feature of figural rating scales). This may be attributed to the measures original
purpose of assessing body image concerns in eating disordered females. As such, body
dissatisfaction is conceptualized as diverging from the thin ideal and attributed simply to
ones concern with being too large or fat. The scale thereby, fails to address muscularity
concerns and excludes evaluation of body sites most salient to males (i.e. shoulders, chest,
arms) (Cafri & Thompson, 2004). Although attempts have been made to modify this scale for
use among boys by including measures of biceps and chest (Jones, Bain & King, 2008), it still
fails to discriminate those desiring a bigger shape from those wishing to be smaller. Thus the
EDI-BD does not adequately assess male body image concerns among those striving for the
muscular ideal. However, with adequate internal reliability demonstrated among children
aged 11 to 18 years, and girls as young as 8 years, this scale represents a particularly
promising measure of body dissatisfaction for girls (Erickson & Gerstle, 2007; Shore &
Porter, 1990; Wood, Becker & Thompson, 1996).
The Body Esteem Scale (Mendelson & White, 1982; 1993), another frequently used
questionnaire, has an advantage over many of the available body image scales as it was
developed specifically for children. Comprising 24 items, the scale explores childrens
feelings about their bodies and their beliefs about how others view them on the basis of a
yes/no response, thus tapping into affective and cognitive dimensions of body image.
Adequate test-retest reliability and internal consistency has been demonstrated among boys
and girls (Mendelson, White, & Mendelson, 1996). More recently, an extended version of the
body esteem scale was developed for adolescents and adults which contains three subscales
pertaining to general feelings about appearance, weight satisfaction, and evaluations
attributed to others about one's body and appearance (Mendelson, Mendelson & White,
2001). The development of separate measures for children and adolescents is a promising tool
for longitudinal research. That is, different scales are often required to facilitate the cognitive
capacities of children, with more advanced versions needed to illicit greater information
among adolescents.
The growing recognition of male body image dissatisfaction in recent years has shifted
the focus towards developing scales with an emphasis on muscular appearance concerns
(Thompson & Cafri, 2007). These measures tap into the idea that male body dissatisfaction
results from the belief that one is too small and lacks muscular definition as opposed to being
too big, which is typically the case among girls (Yanover & Thompson, 2009). Some of these
measures also include a behavioral indicator of body dissatisfaction, recording engagement in

different strategies performed to attain the sociocultural ideal (e.g. weightlifting, diet,
steroids). Thus, these measures incorporate both evaluative as well as investment dimensions
of body image.
The Drive for Muscularity Scale (McCreary & Sasse, 2000) provides a measure of
attitudes and behaviors regarding muscular appearance. Comprising fifteen-items rated on a
6point likert scale, this measure demonstrates good validity, internal consistency and test-
retest reliability among adolescent males aged between 11 and 18 years (McCreary & Sasse,
2000; Smolak & Stein, 2006). However attempts at modifying the scale for preadolescent
boys (as young as eight years) proved unsuccessful with factor analysis failing to replicate the
original structure (Smolak & Stein, 2006; Harrison & Bond, 2007). The disparity between
preadolescents and adolescents may be due to the items pertaining to diet supplements and
weight training, behaviors that are less accessible for younger children (Ricciardelli et al.,
2009). It is therefore important that future work is undertaken with young boys in an attempt
to identify and understand the body image concerns evident at this earlier stage, and to inform
scales that can tap into such concerns (Ricciardelli & McCabe, 2001).
While the DMS addresses muscular concerns among males, it fails to address those
individuals who would like to be smaller and express a desire to lose body fat. The Body
Change Inventory (Ricciardelli & Mcabe, 2002) however, addresses both criterions and taps
into the behavioral investment dimension of body image. Developed for use among
adolescents, the scale assesses strategies to increase body size, decrease body size and
strategies to increase muscle size, encompassing body image concerns of boys and girls. High
reliability and internal consistency, along with good concurrent and discriminant validity have
also been reported among boys and girls (Ricciardelli and McCabe, 2002; McCabe, &
Ricciardelli, 2004). As the measure was validated with children as young as eleven years of
age, it will be necessary to validate this measure on a younger sample to verify its utility with
preadolescent children.
Thus, questionnaires provide a time and cost-effective means of accessing group data.
Moreover they can be read aloud to younger children. Global measures of body
dissatisfaction should be used with caution however, as scales combining or failing to address
specific dimensions of body image limit the conclusions that can be drawn regarding
underlying body concerns (Thompson, 2004).
The questionnaires discussed so far have centered mostly on the evaluative dimension of
body image while neglecting body image investment. The Appearance Schemas Inventory
Revised (ASI-R; Cash, Melnyk, &Hrabosky, 2004) provides a measure of adult beliefs and
assumptions about the importance, meaning and effects of appearance in ones life. Questions
are designed to tap into self-evaluative and motivational dimensions of appearance schemas,
with higher scores reflecting increased vulnerability to appearance relevant messages and
stronger beliefs that appearance is influential and central to self-evaluation. Thus, the ASI-R
evaluates the cognitive outcomes underpinning or following schematic processing (e.g.
beliefs, and evaluations about appearance), as opposed to measuring schematic processing
directly (Ingram, Miranda, & Segal, 1998). Strong internal consistency and convergent
validity with other measures of body image and psychosocial functioning has been evidenced
(Cash et al, 2004). Whilst no comparable measure exists for children and adolescents, Clark
and Tiggemann (2007) recently adapted the ASI-R to produce the Childrens Appearance
Schemas for use with girls aged between 8 and 13 years. Adequate internal reliability was
demonstrated among this sample however further research will be needed to confirm the
psychometric stability of this instrument among boys and girls (Clark & Tiggemann, 2007).
Implicit Measures
Self-report measures assess explicit attitudes or evaluations under cognitive control. Such
methods should therefore be supplemented with implicit stimuli to gain a greater insight into
appearance-related behaviours and attitudes that children and adolescents may be unaware of
or unwilling to report. Accordingly, implicit measures are designed to tap into the automatic
nature of schema activation and processing of appearance related information (Tiggemann,
Hargreaves, Polivy, & McFarlane, 2004). The presentation of schema-relevant stimuli is
typically used to prime or activate a pre-existing self-schema (Altabe & Thompson, 1996).
Word-stem completion tasks may be used to assess implicit schema activation following
experimental exposure to appearance-related television commercials containing images of
women who epitomize the sociocultural ideal. Tiggemann and colleagues (2004) developed a
task comprising twenty word stems that participants completed using the first word that
comes to mind. Word stems can be completed to form appearance or non-appearance related
words (e.g. PRE could be completed as pretty or present), with the total number of
appearance related words generated representing the overall task score. Tiggemann et al
(2004) found that both male and female adolescents generated more appearance-related words
following media image exposure, while Hargreaves and Tiggemann (2003) indicated that
televised images of attractiveness resulted in greater schema activation and body
dissatisfaction among teenage girls. Thus, the word-stem completion task provides a quick
and straightforward implicit test of the effects of exposure to media images, which can be
individually or group-administered. Most research incorporating this instrument however, has
typically focused on adult female reactions, ignoring the effects of media images containing
the muscular ideal on male schema activation. Implementing this method with boys and girls
using gender-specific cultural ideals may therefore provide greater insight into the
developmental nature of appearance schemas and their role in body image dissatisfaction.
The Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) is a
measure of implicit attitudes, which demonstrates acceptable test-retest reliability and internal
consistency (Nosek, Greenwald, & Banaji, 2005). Visual or reading material may be
presented to participants prior to performing this test. Participants must then rapidly
categorize items that appear on screen into superordinate categories using allocated computer
keys. For example, participants may be asked to classify words into descriptive categories
labeled good and bad. The reaction time is used to determine implicit memory-based
associations that take place without conscious introspection. Processing speed therefore
provides an indirect measure of the individuals degree of association between two constructs,
and this degree of implicit association reflects an individuals implicit attitude. In line with
this, schema-congruent data should be processed more quickly and consistently than schema-
incongruent information. For example, girls who aspire to a thin ideal should be faster at
associating positive attribute with thin than fat. Teachman, Gapinski, Brownell, Rawlins &
Jeyaram (2003) demonstrated strong implicit anti-fat attitudes and stereotypes using the IAT
among adult participants. Studies undertaken with children and adolescents however, are
limited. Most research has focused on explicit measures of body dissatisfaction with this age-
group. However, introducing implicit measures may facilitate a greater understanding of body
image dissatisfaction.
PERCEPTUAL MEASURES
Perceptual measures evaluate ones mental representation of their own body (Gardner,
1996). Participants must adjust distorted video or photographic images of their body until it
resembles their current figure. The shape and size of specific body parts can also be modified
to resemble ones physical appearance (Gardner & Brown, 2010). Whole-body or body-site
accuracy is subsequently determined on the basis of how closely ones body estimates match
actual body size or body parts.
Gardner and Boice (2004) proposed a video distortion technique known as the staircase
method for use with children. Beginning with an initial presentation of the childs distorted
body, the image changes become gradually wider or thinner until the child selects an image
that resembles their current body size. In this manner, perceptual methods overcome
limitations of other body image assessment techniques. The issue of scale coarseness is
eliminated, a problem associated with figural rating scales. That is, while body image
dissatisfaction is a continuous variable, most scales comprise nine or less figures, forcing
participants to make a choice based on a few discrete response options. Thus, information is
lost as a consequence of scale coarseness (Gardner & Brown, 2010; Cafri & Thompson,
2004). In addition, the limited number of figures available for selection, and the relatively
exaggerated distortions between adjacent figures results in participants making decisions on a
limited subset of the scale (Gardner, Friedman, & Jackson, 1998).
However, as with figural ratings scales, perceptual measures reflect a conceptual problem
regarding the evaluation of size accuracy among males. Given that females typically aspire to
a thin body ideal, overestimation of body size is simply attributed to feelings of
dissatisfaction with ones current size and the subsequent belief that one is larger than they
actually are. Among males however, it is unclear whether adiposity or muscularity
appearance concerns underpin the perceived discrepancy, as estimations of body size combine
these separate facets of appearance. Perceptual assessments based on size accuracy, while
appropriate for females may therefore fail to tap the true nature of body image concerns
among males (Cafri & Thompson, 2004). In response to this problem, Gruber and colleagues
(1999) developed the somatomorphic index, a digital program that presents figures differing
with respect to body composition and muscularity, enabling identification of the dimension of
appearance causing dissatisfaction. Although this measure demonstrates less than adequate
test-retest reliability, good construct validity is evidenced and it is frequently used to evaluate
body dissatisfaction among adult male samples. This method however has not been used with
children; therefore research is needed to determine how effective or reliable such a measure
would be with a younger population.
Perceptual measures are evidently more time consuming than questionnaire and figural
rating scales and a certain degree of skill is needed to run the procedure (Gardner & Brown,
2010). By using an individuals image however, perceptual methods provide a measure of
body dissatisfaction that has cross-cultural validity and is suitable for use among different
ethnicities (Gardner & Brown, 2010). The existing research also suggests that this measure is
accurate among children aged between 6 and 14 years of age (Gardner, Friedman, Stark, &
Jackson, 1999). However, among younger children, it may be difficult to maintain the longer
periods of concentration necessary to complete the task (Gardner, 2002). Moreover, as
mentioned previously, Thompson and Gardner (2002) posited that individuals might be able
to correctly identify whether an image has been distorted while simultaneously maintaining a
bias in reporting that his or her body is too wide or too thin.
CONCLUSION
In deciding the most appropriate method of assessment of body image to use with
children and adolescents, a number of factors need to be taken into consideration. Most
importantly, measures should be utilized with the age group for which they are intended, that
is, using a sample similar to that upon which they were standardized (Thompson, 2004).
Previous studies have often adapted adult measures for use with children; however these
scales may fail to tap body concerns specific to younger populations. Accordingly, it is
recommended that measures be developed specifically for, and validated with children and
adolescents (Yanover & Thompson, 2009).
It is also advisable when possible, to use separate measures for assessing body image
concerns among young children and adolescents to facilitate the cognitive and physical
changes experienced during pubertal transitions. For example, as previously mentioned,
childrens figural scales would not be suitable for young adolescents because the images do
not reflect the developing and changing adolescent body, thereby making relevant body
ratings and comparisons difficult among this group (Yanover & Thompson, 2009). Visual
scales may also be more appropriate for younger children who can find it hard to verbally
express their ideal and actual figure representations owing to developmental capacities
(Tremblay & Limbos, 2009).
In addition, methods of assessing body image should demonstrate adequate reliability
(e.g. internal consistency, test-retest) achieving Nunallys (1970) criteria of 0.70. Other
psychometric properties should be evidenced including good concurrent validity of body
image measures with ones actual body (i.e. BMI, weight, and body fat) and convergent
validity with other scales assessing body dissatisfaction (Smolak, 2004; Thompson, 2004).
The empirical research indicates that few measures of body dissatisfaction reporting adequate
psychometric properties are available for use with preschool children (Smolak, 2004;
Tremblay & Limbos, 2009). However, given that body dissatisfaction has been evidenced in
children as young as five to seven years of age (Birbeck & Drummond, 2005; Krahnstoever-
Davison, Markey & Birch, 2003; Gardner et al., 1999), it is vital that research is focused on
developing and validating measures of body dissatisfaction suitable for use with this age-
group. The inclusion of a measure of appearance schemacity is also recommended in body
image dissatisfaction evaluation among children, as it is purported that children must firstly
learn the salience of appearance before experiencing negative affective consequences.
In view of the gendered body image patterns evidenced among children and adolescents,
measures of body dissatisfaction should include dimensions of weight loss and muscular
appearance. It may also be necessary to examine whether global measures actively tap body
concerns among both boys and girls, or whether gender specific measures are needed.
Moreover, it is important to identify the aspect of body image that is under investigation. For
instance, dissatisfaction with appearance should be discriminated from concern or investment
in appearance. In accordance, the Multidimensional Body-Self Relations Questionnaire
(Brown, Cash, & Mikulka, 1990) comprises orthogonal scales that separately tap into each
component. Providing a variety of body image assessment techniques that represent different
components of body image will facilitate a broader interpretation and understanding of this
construct, as opposed to conclusions based on a solitary scale (Thompson, 2004).
When analyzing body image findings, data should be organized by gender, age and
weight categorization. In doing so, developmental norms can be established and a suitable
baseline can be devised enabling children to be evaluated in terms of representative body
image data (Tremblay & Limbos, 2009). Furthermore, as the majority of studies have utilized
correlational data obtained from cross-sectional research, longitudinal research designs with
appropriate follow-up periods are needed to enhance our understanding of the developmental
nature of body dissatisfaction (Ricciardelli & McCabe, 2001). These approaches may, in turn,
provide insight into the origins of body dissatisfaction during childhood and how it manifests
and develops over time.
Future research should also focus on developing measures of body dissatisfaction that are
applicable to children of different ethnicities. The vast majority of measures are developed
and validated against white populations, with items failing to translate cross-culturally and
scales failing to address cultural values of minority groups (Smolak, 2004). Thus, it is
apparent that much work still remains to be done in terms of identifying suitable measures of
body dissatisfaction among girls and boys, children and adolescents. In conclusion, the
reliability and validity properties of different scales, the dimension of body dissatisfaction to
be assessed, the age and maturity level of the sample and the intended purpose of the research
should all be taken into consideration when deciding on the most suitable method of
assessment of body image to use with children and adolescents (Gardner & Brown, 2010).
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Chapter 14
ISSUES PERTAINING TO BODY IMAGE

MEASUREMENT IN EXERCISE RESEARCH
Rebecca L. Bassett and Kathleen A. Martin Ginis

McMaster University, Hamilton, Ontario, Canada
ABSTRACT
Recent meta-analyses have established a positive relationship between exercise and
body image [Hausenblas & Fallon, 2006; Reel, 2007; Campbell & Hausenblas, 2009].
However, further research is necessary to answer numerous remaining questions
regarding the relationship between exercise and body image. For example, the
mechanisms by which exercise interventions improve body image are not well
understood. Likewise, characteristics of the most effective exercise programs for
enhancing body image remain unknown. Future research should aim to understand such
ambiguities regarding the exercise-body image relationship. In order to maximize the
impact of future exercise research, proper measurement of body image is critical.
Several important considerations for the measurement of body image were
highlighted in an article by Thompson [2004]. In the current commentary, Thompsons
article is used as a framework for discussion of issues pertaining to body image
measurement specifically with regard to exercise research. Five considerations are
addressed: 1] Defining the specific dimension of body image being considered and
measure accordingly. 2] Considering multiple measures of body image. 3] Selecting valid
and reliable body image measures. 4] Considering sample characteristics. 5] Considering
the appropriateness of state or trait body image measures. The commentary will serve as
a useful guide for proper measurement of body image within exercise research.
INTRODUCTION
Body image dissatisfaction is an increasingly prevalent issue within contemporary
society. Popular media bombards North Americans with images of desirable bodies. For
women, the cultural body ideal is an ultra-thin, curvy, lean, and toned physique [Gruber,
2007]. The cultural body ideal for men is a V-shaped physique with broad, muscular
246 Rebecca L. Bassett and Kathleen A. Martin Ginis
shoulders, lean and toned abdominals, and muscular legs [Leit, Pope, & Gray., 2000;
Olivardia, Pope, Boroweicki, & Cohane, 2004]. Billions of dollars are spent each year in
North America on countless products promising the achievement of these largely unattainable
bodies displayed in the media [Franz et al., 2007]. Accordingly, many women and men
develop body dissatisfaction as a result of their failure to achieve the impossible.
The costs of body dissatisfaction go far beyond the dollars spent on desperate attempts to
change ones body. Body dissatisfaction, or poor body image, can have many physical and
psychological health implications. Body image dissatisfaction is a principal component and
predictor of numerous psychological health problems including depression, anxiety [Stice &
Whitenton, 2002], and low self-esteem [Miller & Downey, 1999]. Further, poor body image
is related to health-risk behaviors including smoking, alcohol and drug use [French et al.,
1995], and the development of eating disorders [Polivy & Herman, 2002]. Considering the
extent of body dissatisfaction in contemporary society and the health implications of poor
body image, treatment for body image dissatisfaction has become an important research
objective.
In the last two decades, empirical research has expanded to support exercise as treatment
for body image dissatisfaction. Meta-analytic evidence suggests that exercise is a viable
means of improving poor body image [Campbell & Hausenblas, 2009; Hausenblas & Fallon,
2006; Reel et al., 2007]. However, further research is necessary to answer numerous
remaining questions regarding the relationship between exercise and body image. For
example, the mechanisms that explain the positive impact of exercise on body image are not
well understood. A review of experimental exercise-body image literature identified three
potential mechanisms to explain the positive effects of exercise on body image [Martin Ginis,
Bassett, & Conlin, 2010]. These mechanisms are: objective changes in physical fitness,
perceived changes in physical fitness, and changes in physical self-efficacy. However, most
mechanism research has focused only on objective changes in physical fitness and has all but
ignored the other potential mechanisms. Further, most studies have failed to examine
potential mechanisms through study designs and statistical analyses which adequately test for
mediation.
Likewise, characteristics of the most effective exercise programs for enhancing body
image remain unknown. Martin Ginis and Bassett [2010] summarized what is known about
the ideal frequency, intensity, duration, and types of exercise most suited to improve body
image, and emphasized the need for further research to better understand exercise
characteristics which moderate the exercise-body image relationship. Again, most research
studies have failed to examine potential exercise characteristics with study designs and
statistical analyses which adequately test for moderation. Until mechanisms and moderators
are better understood, maximally effective exercise interventions cannot be implemented to
improve body image.
In order to maximize the impact of future exercise and body image research, proper
measurement of body image is critical. Several important considerations for the measurement
of body image, in general, were highlighted in an article by Thompson [2004]. In the current
chapter, the strategies suggested by Thompson are used as a framework for a discussion of
issues pertaining to body image measurement in exercise research in particular.
Issues Pertaining to Body Image Measurement in Exercise Research 247
1. DEFINING THE SPECIFIC DIMENSION OF BODY IMAGE BEING

CONSIDERED AND MEASURING ACCORDINGLY
The term body image can refer to ones feelings, actions, thoughts, and perceptions about
ones body. Thus, an important first step in exercise-body image research is to acknowledge
the four body image dimensions [i.e., affective, behavioral, cognitive, perceptual] and define
the dimension being investigated. Likewise, it is imperative to choose a measure that assesses
the specific body image dimension of interest.
Measures of affective body image should capture feelings and emotions, such as anxiety
and pride, as they are related to the body. Alternatively, behavioural body image measures
are concerned with actions performed in response to body image disturbance such as dieting,
body checking, or avoiding mirrors. The cognitive dimension of body image is assessed by
measures of body satisfaction, including assessment of attitudes, thoughts, and beliefs about
ones body. Finally, perceptual body image reflects individuals level of accuracy in judging
the size, or function, of their body or body parts. Thompson notes that there are currently
more than 50 measures available to assess body image a reality that leads to both choice and
confusion for exercise researchers. For example, across 37 exercise and body image studies
included in a meta-analysis [Hausenblas & Fallon, 2006], more than 25 different body image
measured were used.
In their review, Martin Ginis, Bassett and Conlin [2010] reported that experimental
exercise-body image research has largely emphasized measures of the cognitive, and to a
lesser extent, affective dimensions of body image. Yet exercise interventions may
differentially affect individuals thoughts, feelings, perceptions, and behaviours toward their
bodies. For instance, a six-month exercise program consisting of twice-weekly, moderate
intensity aerobic exercise lead to significant improvements in affective, but not cognitive,
dimensions of body image in a sample of sedentary women [Lindwall & Lindgren, 2005].
Given the possibility that an intervention can differentially influence the body image
dimensions, researchers are encouraged to measure change in all four dimensions rather than
assume findings are generalizable across the various body image dimensions. Doing so would
advance knowledge regarding the dimensions of body image most likely to improve in
different populations or following specific types of exercise interventions.
In addition to the four dimensions of body image, physical appearance and physical
function have also been shown to be independent aspects of body image [Reboussin et al.,
2000]. Considering both appearance and function may be particularly important in
experimental exercise-body image research. Exercise may impact the four dimensions of
body image differently as they relate to the appearance and function of ones body.
Considering the cognitive dimension of body image as an example, exercise may have
different effects on satisfaction with appearance and satisfaction with function. For instance,
one study found that among men living with spinal cord injury, participation in exercise was
negatively related to satisfaction with function, yet was unrelated to satisfaction with
appearance [Bassett, Martin Ginis, & The SHAPESCI Research Group, 2009]. For these men,
appearance-related reasons for exercise [e.g., improve appearance through weight loss] may
have been superseded by function-related motives [e.g., improve strength to transfer oneself
independently]. Dissatisfaction with physical function may have motivated some men to
exercise in order to improve or restore physical function.
The distinction between appearance- and function-related aspects of body image may be
particularly important for people who may place greater value on physical function versus
appearance such as men [Martin Ginis, Eng, Arbour, Hartman, & Phillips, 2005], people with
disease [Lichtenberger, Martin Ginis, MacKenzie, & McCartney, 2003] or disabilities
[Bassett et al., 2009], and older adults [Reboussin et al., 2000]. When studying the effects of
exercise on body image in these groups, researchers should distinguish between appearance
and function aspects of body image and choose measures accordingly. Furthermore, given
that most exercise research to date has focused on dimensions of body image in relation to
physical appearance, future research should extend assessment to functional aspects of body
image in order to generate a more comprehensive understanding of the effects of exercise on
body image.
2. CONSIDERING MULTIPLE MEASURES OF BODY IMAGE

When designing an exercise intervention study, it is important to choose body image
measures that maximize the likelihood of detecting significant intervention effects. Thompson
[2004] suggests employing multiple measures of body image, to tap into the different body
image dimensions, and to facilitate exploratory research where group comparisons [e.g.,
based on sex, age, ethnicity] are of interest. The inclusion of multiple body image measures
may allow researchers to observe changes in one dimension of body image [e.g., cognitive]
within one group [e.g., men], and changes in another dimension [e.g., affective] within
another group [e.g., women]. Likewise, multiple body image measures may be appropriate for
a research study aiming to compare the effects of a treatment on specific domains of body
image. For instance, by using multiple measures in an exercise training study, investigators
could determine which dimensions of body image are most susceptible to improvement
through exercise intervention, thus maximizing the information that can be gleaned from a
single experiment.
Multiple measures may also be advantageous when conducting research to test or develop
a theory or model, such as the conceptual model of factors contributing to the development of
muscle dysmorphia [Grieve, 2007], which includes multiple body image dimensions [i.e.,
perceptual, cognitive and behavioral]. There are few theoretical-frameworks to guide
exercise-body image research and thus there is a need to develop theories and models to guide
future body image research in exercise psychology. Through the development of good
theories, exercise scientists can identify key variables to target in intervention research and
clarify mediating variables by which exercise impacts body image [cf. Baranowski,
Anderson, & Carmack, 1998]. It is critical that these theories and models be developed in
recognition of body image multidimensionality. Accordingly, multiple measures of body
image should be employed when testing and developing such theoretical frameworks.
Some exercise scientists have already employed multiple measures of body image in their
research. For example, Lindwall and Lindgren [2005] included measures of the affective [i.e.,
social physique anxiety] and cognitive [i.e., multiple body self relations] dimensions.
Likewise, Martin Ginis and colleagues [2005] measured affective, cognitive, and perceptual
body image. Where appropriate, researchers are encouraged to continue this approach, while
using caution and thoughtful consideration when determining which measures to include.
3. SELECTING VALID AND RELIABLE BODY IMAGE MEASURES

Reliability and validity reflect the consistency and accuracy of a measures ability to
assess a construct and are important psychometric properties of body image measures
employed in experimental research [Streiner & Norman, 1995]. Both test-retest and internal
consistency reliability should be considered when determining if a measure is reliable.
Likewise, investigators are advised to look for evidence of construct, predictive, and
discriminative validity when choosing a body image measure. For experimental research
where changes in body image are assessed following an exercise intervention, it is important
to choose a measure that has shown responsiveness to experimental manipulation of exercise.
Otherwise, investigators risk failing to detect exercise-induced body image changes. As
Thompson [2004] notes, the multitude of existent body image measures leaves little room to
justify the use of a new measure without established psychometrics.
In general, exercise researchers have shown great care in choosing valid and reliable
body image measures for their studies. Indeed, body image measures with established validity
and reliability were employed in 54 of the 57 studies included in Campbell and Hausenblas
[2009] meta-analyses of the effects of exercise interventions on body image. Researchers in
the exercise science field are encouraged to continue in this manner, in order to accurately
measure body image and advance knowledge regarding the relationship between exercise and
body image.
4. CONSIDERING SAMPLE CHARACTERISTICS

When choosing a measure of body image, it is imperative to consider characteristics of
the sample under investigation for two reasons. First, it is necessary to consider the
appropriateness of the measure for the study sample. Most exercise and body image research
has focused on healthy women, but there is much to be gained from studying other
populations that may also have body image concerns such as men, people with disabilities,
and women who are pregnant. However, not all body image measures adequately tap into the
body image concerns of all populations. For example, the body dissatisfaction subscale of the
eating disorder inventory [Garner, Olmstead, & Polivy, 1983] is a measure of body image
primarily focused on body dissatisfaction relative to a thin body ideal [Cafri & Thompson,
2004] and may not be appropriate for a sample of young men who may be more concerned
with muscularity than thinness. Alternatively, the drive for muscularity scale [McCreary &
Sasse, 2000], which captures body concerns related to muscularity per se, may be a more
appropriate measure for this population. In some cases an existing measure may be
appropriate to assess body image within a particular sample. Alternatively, adaptations or
modifications to an existing measure may be the solution. Second, it is necessary to determine
the reliability and validity of a body image measure for the study sample since psychometric
properties may vary across samples with different characteristics [e.g., men vs. women, older
vs. younger].
Thompson [2004] suggests that changing the wording of a scale or including additional
items may transform an inappropriate existent scale into the ideal measurement tool for a
given sample. For example, Hicks and colleagues [2003] used the Adult Body Satisfaction
Scale [Reboussin et al., 2000] to measure the cognitive dimension of body image among
people with spinal cord injury. However, an item was added to measure satisfaction with arm
strength, as this is a significant component of satisfaction with physical function for people
with spinal cord injury. The revised scale had acceptable internal consistency [Cronbachs
>.70] suggesting that the additional item was appropriate for inclusion in the original scale. In
deed, a high internal consistency indicates that participants were giving similar responses to
all items in the scale, suggesting all items were tapping into a common set of body image
concerns [i.e., satisfaction with physical function]. This thoughtful alteration allowed the
researchers to use an extant measure with established psychometric properties rather than
initiating the development and validation of a new measure. Thompson cautions that it is
good practice to ask for permission from the author of the original measure before making
alterations to it.
Although a measure [with or without adaptations] may be suitable for a given sample,
there may still be individual differences to take into account when examining exercise related
changes in that measure. For example, within a sample of undergraduate students, differences
in body image responses to exercise may exist between men and women, healthy and
overweight people, regular exercisers and non-exercisers. Hausenblas and Fallon [2006]
considered exerciser characteristics such as gender, age, and fitness level as moderators in
their meta-analysis. Although exercise resulted in improved body image regardless of
exerciser characteristics, the size of the effect varied depending on participants age group
and gender. Likewise, Martin Ginis and Bassett [2010] discussed moderators of the exercise-
body image relationship. Both resources may provide researchers with potential moderators to
consider in future exercise-body image research -- One must consider the diversity of a
sample and consider pertinent moderators in order to advance knowledge regarding the
relationship between exercise and body image. Failure to consider moderator variables may
mask or underestimate the effects of exercise on body image within certain samples.
5. CONSIDERING THE APPROPRIATENESS OF STATE AND TRAIT BODY

IMAGE MEASURES
Exercise can be studied as both an acute intervention [e.g., a single bout of exercise] and
a training intervention [e.g., a 12-week exercise program]. The decision to use a state or trait
measure of body image is entirely dependent upon the research question and study design.
Thompson [2004] explains that the majority of existing measures assess body image as trait
dimension. An example of a trait measure often used in exercise-body image research is the
Social Physique Anxiety Scale [SPAS; Hart et al., 1989], which assesses anxiety related to
the evaluation of ones body. The SPAS might be appropriate for a training study examining
changes in dispositional body image concerns following an eight-week exercise program.
State measures of body image, alternatively, are concerned with the experience of body
image at a specific time. A good example of a state measure of body image is the Body Image
States Scale [BISS; Cash et al., 2002], which requires participants to rate how they feel about
aspects of their body image right now at this very moment. This type of state measure
might be suitable for an exercise study where change in body image is measured throughout
an exercise session, or immediately before and after completing an exercise class. Deciding to
use a state or trait measure is also particularly important for research studies aiming to
understand the mechanisms of the exercise-body image relationship because mechanisms of
body image change may vary between acute exercise and exercise training. Using an
inappropriate measure of body image may lead to erroneous findings regarding mechanisms
of body image change.
CONCLUSION
Thoughtful consideration of the research question, hypotheses, and study design are
necessary for choosing appropriate body image measures. Investigators are encouraged to
consider the dimension[s] of body image best suited to the research question. Likewise, the
type of exercise manipulation and the mechanisms [i.e., mediators] being examined should be
considered. Research seeking to resolve unanswered questions regarding exercise and body
image is encouraged, however, accurate measurement of body image is critical to maximize
the impact of future research. With thoughtful and precise measurement, future exercise
research can continue to develop body image theory and maximally effective treatments for
body image disturbance.
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(2003). Long-term exercise training in persons with spinal cord injury: effects on
strength, arm-ergometry performance and psychological well-being. Spinal Cord, 41, 34-
43.
Leit, R. A., Pope, H. G. Jr., & Gray, J. J. (2000). Cultural expectations of muscularity in men:
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Lichtenberger, C. M., Martin Ginis, K. A., MacKenzie, C. L., & McCartney, N. (2003). Body
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Chapter 15
NEGATIVE BODY IMAGE PERCEPTION AND

ASSOCIATED ATTITUDES IN FEMALES
Tamara Y. Mousa1 and Rima H. Mashal2

1
Researcher Assistant in the Department of Nutrition and Food Science, University of
Jordan. Amman 11196 Jordan, P.O. Box: 960364
2
Assistant Professor of Nutrition
Department of Nutrition and Food Science, University of Jordan, Amman 11942
ABSTRACT
Negative body image perception has predisposed females, particularly adolescent
and young females, to be more preoccupied with their body image than males. This has
been explained by the perception of female beauty with extreme thinness. Western
females are preoccupied with their body image due to social and cultural norms that
emphasize on thinness, which is internalized as a symbol of success. Furthermore, beauty
Western ideals have recently been found to influence body image perception of Arabic
females through mass media. Negative body image perception has been indicated to
contribute to body image dissatisfaction. Because females are concerned about their body
image and weight, they tend to correct imperfections through engaging in negative eating
attitudes and behaviors. It has also been documented that body image dissatisfaction is
associated with acknowledging eating disorders, increasing the risk of exhibiting health
compromising behaviors. In all, well-controlled prospective studies on negative body
image perception and the factors associated with it are encouraged. Research should also
attempt to develop intervention programs to improve body image of females.
1
Correspondence to: Tamara Yousef Mousa, MSc.
Researcher Assistant at the Department of Nutrition and Food Science,
University of Jordan. Amman 11196 Jordan, P.O. Box: 960364
Telephone/Fax number: 00962-6-5604301
E-mail: mousa_tamara@yahoo.com
2
E-mail: rima@ju.edu.jo
256 Tamara Y. Mousa and Rima H. Mashal
Appreciation of body image by societies, in particular by Western societies, has

predisposed females to internalize the social ideals of body attractiveness that emphasize on
thinness (Thompson & Stice, 2001). This has been explained by the perception of female
beauty with extreme thinness (Sweeting & West, 2000). Moreover, thinness (the perceived
ideal of beauty) is desirable to females given that they have learned long before puberty that
beauty is a basic dimension of the feminine gender role (Collins, 1991). In particular, being
slim and fit is worshiped because it symbolizes certain notions such as social acceptance,
social class and success (Abdollahi & Mann, 2001; Shuriquie, 1999). Thus, females are more
likely to be preoccupied with their body image and weight than males fostering negative body
image perception (Khawaja & Afifi-Soweid, 2004).
According to Tiggemann & Lacey (2009), females are known to base their self-worth on
physical appearance and beauty. It is possible that the mirror could be the tool that is used to
assess females self-worth, through physical appearance evaluation, against the sociocultural
body image standard. As a result, comparing oneself with the unattainable unrealistic ideal
has predisposed females to endorse body image dissatisfaction (BID) (Thompson & Stice,
2001). Mass media messages have reinforced the importance of attaining the thin aesthetic
societal ideal (Ba, Ai, Karabudak, & Kiziltan, 2004) by stressing on that self-worth is
based on physical appearance, as well as that slim females are achieving and successful
(Littleton & Ollendick, 2003). In commercial advertisements for instance, mass media uses
very thin models or celebrities in addition to that the portraits of the models in the printed
media are actually computer modified photographic images (Thompson & Stice, 2001). In
line with this, a recent study has verified that reading beauty magazines and observing images
of thin models have initiated females to internalize the societal beauty ideals. Authors have
also shown that exposure to media messages was associated with an increase in BID (Rodgers
& Chabrol, 2009). Monro & Huon (2005) have also observed that young women who were
exposed to media-portrayed idealized images were predisposed to increased body shame,
especially when the body is subjected to scrutiny as in social occasions. Our work (Mousa,
Mashal, Al-Domi, & Jibril, 2010) that investigated BID occurrence among adolescent girls
has replicated these findings, where there was a positive association between adolescent girls
exposure to media messages and dissatisfaction with body image. Explicitly, participants who
made efforts to look like females in the media as well as who exercised and/or dieted to lose
weight because of a magazine article or picture were significantly at higher risk to display
BID by 1.2 and 1.6 folds, respectively (p < 0.01).
Moreover, it has been stated that BID was negatively correlated with self-concept and
self-esteem of young females (20-35 years). Specifically, body image of young females had
an impact on their overall view of self and on their global self-evaluation. This association,
however, was weak in older females (50-65 years) in which age has worked as a protective
factor against BID occurrence in them. The authors explained their results by verifying that as
women age and their bodies deviate from the objectively ideal body, they adopt cognitive
strategies that increase their acceptance of their bodies such as maintaining their self-esteem
(Webster & Tiggemann, 2003).
Another social factor that has been found to contribute to BID is clothing and dressing
styles of females. Although this concept is not studied very much, Tiggemamm & Lacey
(2009) reported that clothing and appearance-management behaviors are associated with BID
occurrence in females. The authors observed that clothes had several functions regarding
body image including assurance, fashion, camouflage, identity and comfort. That is, clothing
Negative Body Image Perception and Associated Attitudes 257
is used to manage and improve the appearance of females and to enhance their feelings about
themselves. Additionally, women with greater body mass index and BID were more likely to
use clothes for camouflage purposes to conceal their perceived imperfections. Findings have
also signified that self-esteem was associated with camouflage and individuality, where the
women with higher self-esteem were less likely to hide their body and more likely to
emphasize and individualize the difference of their body from the ideal. Therefore, the way
females base their self-worth depending on their self-esteem determines their level of
satisfaction with their body and appearance (Tiggemamm & Lacey, 2009). In a similar vein,
Trautmann, Worthy & Lokken (2007) have verified that females who were dissatisfied with
their body image were more likely to participate in clothing-avoidance behaviors such as
avoiding revealing and tight clothes, wearing baggy clothing to cover up their bodies,
avoiding shopping as well.
In adolescent girls, the pubertal changes that involve menarche occurrence and
accumulation of body fat have caused their bodies to deviate from the pre-pubertal thin body
considered ideal (Abraham & ODea, 2001; Sweeting & West, 2002). Physical changes of
puberty thus, have been reported to initiate the endorsement of negative body image
perception among adolescent girls (Presnell, Bearman, & Stice, 2004). Furthermore, several
papers have indicated that besides media messages, peers and parents accentuating on the
importance of having a socially esteemed body, negative family relations and high social
class have provided a fertile environment for the development of BID in adolescent and
young females (Littleton & Ollendick, 2003; McCabe & Ricciardelli, 2001; Presnell et al.,
2004; Soh, Touyz, & Surgenor, 2006). Some reports have supported these findings in which
significant positive associations have been observed between media messages, pubertal
changes, negative comments regarding body weight from parents and peers, as well as high
socioeconomic status and displaying BID in adolescent girls (p < 0.05) (Al-Subaie, 2000;
Mousa et al., 2010).
The Western culture has signified thinness as the ideal body standard for females. This
highlights the high prevalence of BID (20-60%) among adolescent and young females in
Western and developed countries including England and Denmark (El-Ansari, Clausen,
Mabhala, & Stock, 2010), Switzerland, Belgium, Germany, Greece, Norway, Sweden,
France, Italy and Canada (Al-Sabbah, Vereecken, Elgar, Nansel, Aasvee, Abdeen, Ojala,
Ahluwalia, & Maes, 2009), Australia (McCabe & Ricciardelli, 2001), and the United States of
America (Presnell et al., 2004). Recently, beauty Western ideals have been proposed to
influence body image perception of Arabic females, particularly through mass media (Mousa
et al., 2010). Because of globalization and acculturation, Arabic females experience a conflict
between plumpness (the traditional Arabic ideal of beauty) and thinness (the Western ideal of
beauty) contributing to BID (Shuriquie, 1999; Soh et al., 2006). For example, in Amman, the
capital of Jordan, 21.2% of adolescent schoolgirls aged 10-16 years have suffered from BID
(Mousa et al., 2010, a). Subsequent studies in Egypt (7.7%) (Ragab, 2005), Saudi Arabia
(16%) (Al-Subaie, 2000), Palestine (32.1%) (Al-Sabbah, Vereecken, Abdeen, Coats, & Maes,
2008), Qatar (36.2%)* (Bener & Tewfik, 2006), United Arab Emirates (66%) (Eapen,
Mabrouk, & Bin-Othman, 2006), and Bahrain ( 50%) (Al-Sendi, Shetty, & Musaiger, 2004)
that assessed body image perception in adolescent and young females have paralleled this
finding. That is, acculturation and identification with Western norms and values regarding
body shape have been argued to affect body image ideals of Arabic Females (Soh et al.,
2006).
Negative body image perception and its psychological correlates as dysphoria, low self-
esteem and fear of gaining weight or becoming fat are documented to initiate the development
of eating disturbances in females (Littleton & Ollendick, 2003; Soh et al., 2006; Webster &
Tiggemann, 2003). Most studies that examined the importance of body image for females
have indicated that females who endorsed BID have engaged in dieting and aberrant eating
attitudes, developed eating disorders as well (Al-Sabbah et al., 2008; Bener & Tewfik, 2006;
Eapen et al., 2006; Fairburn & Harrison, 2003; Thompson & Stice, 2001). In our study
(Mousa, Al-Domi, Mashal, & Jibril, 2010), adolescent girls who were dissatisfied with their
body image have engaged in negative eating attitudes as binge eating, self-induced vomiting
and substance abuse (i.e.: laxatives, diuretics and diet pills). In addition, the participants who
displayed BID were at higher risk to develop eating disorders as compared to those who were
satisfied with their body image [RR: 5.2 (3.3-8.4), P < 0.001].
Interestingly, the Committee of Sports Medicine and Fitness (1999/2000) has
demonstrated that aesthetic sports and competitive pressures for exceptional performance
have enhanced the preexisting social pressures for females to be thin. Consequently, the
importance of being thin has disposed athletic females to endorse BID and eating
disturbances (Anderson, Griesemer, Johnson, Martin, McLain, Rowland, & Small, 2000).
Body image dissatisfaction combined with eating disorders is signified to increase the
risk of females in general and adolescent girls in particular, to exhibit health compromising
behaviors (Anderson et al., 2000; Mitchell & Crow, 2006). These disorders have predisposed
a number of medical complications in females including anxiety, weakness, amenorrhea,
anemia, electrolyte imbalance, osteopenia, emaciation, as well as dermatologic abnormalities
as Russells sign and xerosis, gastrointestinal problems as constipation, diarrhea and dental
problems, cardiovascular and pulmonary problems as arrhythmias and pneumomediastinum
(Fairburn & Harrison, 2003; Mitchell & Crow, 2006). Hence, the need for interventional
studies is pivotal to control the occurrence of the adverse health effects of eating and body
image disturbances in females.
In conclusion, body image seems to be an important concept in self-evaluation of
females. Body image dissatisfaction is known to be affected by many factors including
physical changes of the body throughout life span, peers and parental pressures towards
thinness, mass media messages, and acculturation. Further, negative body image perception is
associated with eating disturbances, which eventually result in displaying serious health
problems. The diagram in Figure (1) summarizes the factors that contribute to BID which
initiates the development of eating disturbances, leading to medical complications.
Therefore, well-controlled case-control studies on negative body image perception and
the risk factors associated with it are encouraged. Future research should also focus on
developing interventional studies that target self-evaluation and self-concept to help in
improving body image perception of females. Finally, epidemiologic investigation is needed
to assist in controlling the occurrence of body image and eating disturbances in females and
the impact of these disturbances on their health.
Figure 1. Factors Predisposing Body Image Dissatisfaction, Eating Disturbances, and Medical
Complications.
NOTE
* We calculated the percentage of adolescent girls who were dissatisfied with their body
image.
REFERENCES
Abdollahi, P., & Mann, T. (2001). Eating disorders symptoms and body image concerns in
Iran: Comparisons between Iranian women in Iran and in America. International Journal
of Eating Disorders, 30, 259-268.
Abraham, S., & ODea, J. (2001). Body mass index, menarche, and perception of dieting
among peripubertal adolescent females. International Journal of Eating Disorders, 29,
23-28.
Al-Sabbah, H., Vereecken, C., Elgar, F., Nansel, T., Aasvee, K., Abdeen, Z., Ojala, K.,
Ahluwalia, N., & Maes, L. (2009). Body weight dissatisfaction and communication with
parents among adolescents in 24 countries: international cross-sectional survey. BMC
Public Health, 9, 52-61.
Al-Sabbah, H., Vereecken, C., Abdeen, Z., Coats, E., & Maes, L. (2008). Associations of
overweight and of weight dissatisfaction among Palestinian adolescents: findings from
the national study of Palestinian schoolchildren (HBSC-WBG2004). Journal of Human
Nutrition & Dietetics, 22, 40-49.
Al-Sendi, A., Shetty, P., & Musaiger, A. (2004). Body weight perception among Bahraini
adolescents. Child: Care, Health & Development, 30, 369376.
Al-Subaie, A. (2000). Some correlates of dieting behavior in Saudi schoolgirls. International
Anderson, S., Griesemer, B., Johnson, M., Martin, T., McLain, L., Rowland, T., & Small, E.
(2000). Medical Concerns in female athletes. Pediatrics, 106, 610-613.
Ba, M., Ai, F., Karabudak, E., & Kiziltan, G. (2004). Eating attitudes and their
psychological correlates among Turkish adolescence. Adolescence, 39, 593-599.
Bener, A., & Tewfik, I. (2006). Prevalence of overweight, obesity, and associated
psychological problems in Qataris female population. Obesity Reviews, 7, 139-145.
Collins, E. (1991), Body figure perceptions and preferences among preadolescent children.
Eapen, V., Mabrouk, A-A., & Bin-Othman, S. (2006). Disordered eating attitudes and
sympto-matology among adolescent girls in the United Arab Emirates. Eating Behaviors,
7, 53-60.
El-Ansari, W., Clausen, S., Mabhala, A., & Stock, C. (2010). How do I look? Body image
perception among university students from England and Denmark. International Journal
of Environmental Research & Public health, 7, 583-595.
Fairburn, C., & Harrison, P. (2003). Eating disorders. The Lancet, 361, 407-416.
Khawaja, M., and Afifi-Soweid, R.A. (2004). Images of body weight among young men and
women: Evidence from Beirut, Lebanon. J Epidemiology & Community Health, 58, 352-
353.
Littleton, H., & Ollendick, T. (2003). Negative body image and disordered eating behavior in
children and adolescents: What places youth at risk and how can these problems be
prevented? Clinical Child and Family Psychology Review, 6, 51-66.
McCabe, M., & Ricciardelli, L. (2001). Parent, peer, and media influences on body image and
strategies to both increase and decrease body size among adolescent boys and girls.
Mitchell, J., & Crow, S. (2006). Medical complications of anorexia nervosa and bulimia
nervosa. Current Opinion in Psychiatry, 19, 438-443.
Monro, F., & Huon, G. (2005). Media-portrayed idealized images, body shame, and
appearance anxiety. International Journal of Eating Disorders, 38, 85-90.
Mousa, T., Al-Domi, H., Mashal, R., & Jibril, M. (2010). Eating disturbances among
adolescent schoolgirls in Jordan. Appetite, 54, 196-201.
Mousa, T., Mashal, R., Al-Domi, H., & Jibril, M. (2010). Body image dissatisfaction among
adolescent schoolgirls in Jordan. Body Image: An International Journal of Research, 7,
46-50
Presnell, K., Bearman, S., & Stice, E. (2004). Risk factors for body dissatisfaction in
adolescent boys and girls: A prospective study. International Journal of Eating
Disorders, 36, 389-401.
Ragab, S. (2005). Media messages and womens body perceptions in Egypt. Unpublished
Master Dissertation, Georgia State University, USA.
Rodgers, R., & Chabrol, H. (2009). The impact of exposure to images of ideally thin models
on body dissatisfaction in young French and Italian women. L'Encphale, 35, 262-268.
Shuriquie, N. (1999). Eating disorders: A transcultural perspective. Eastern Mediterranean
Health Journal, 5, 354-360.
Soh, N., Touyz, S., & Surgenor, L. (2006). Eating and body image disturbances across
cultures: A review. European Eating Disorders Review, 14, 54-65.
Sweeting, H., & West, P. (2002). Gender differences in weight related concerns in early to
late adolescence. J Epidemiology & Community Health, 56, 700-701.
Thompson, J., & Stice, E. (2001). Thin-ideal internalization: Mounting evidence for a new
risk factor for body-image disturbance and eating pathology. Current Directions in
Psychological Science, 10, 181-183.
Tiggemann, M., & Lacey, C. (2009). Shopping for clothes: Body satisfaction, appearance
investment, and functions of clothing among female shoppers. Body Image: An
International Journal of Research, 6, 285-291.
Trautmann, J., Worthy, S., & Lokken, K. (2007). Body dissatisfaction, bulimic symptoms,
and clothing practices among college women. The Journal of Psychology, 141, 485-498.
Webster, J., & Tiggemann, M. (2003). The relationship between womens body satisfaction
and self-image across the life span: The role of cognitive control. The Journal of Genetic
Chapter 16
BODY IMAGE IN YOUNG AND ADULT WOMEN WITH

PHYSICAL DISABILITIES
Nancy Xenakis1 and Judith Goldberg2

1
Program Coordinator
Initiative for Women with Disabilities
NYU Hospital for Joint Diseases
New York, NY 10003 USA
2
Director
Initiative for Women with Disabilities
NYU Hospital for Joint Diseases
New York, NY 10003 USA
ABSTRACT
Recent literature has shown that women with physical disabilities often face physical
and emotional barriers to their own health and wellness. Persons with disabilities are
often seen as others in relation to the general population. Attitudes toward people with
physical disabilities are generally negative, simplistic and discriminative. Moreover,
women with a physical disability must deal with Westernized gender roles and beauty
ideals that are constantly imposed upon them. As a result, this group of women often has
difficulty developing a healthy image of their bodies, socializing and expressing
themselves, especially when compared with their able-bodied counterparts.
In particular, young women, as they reach adolescence, develop a growing
awareness of just how different their bodies are when compared with their able-bodied
peers. This unhealthy self concept is often perpetuated by the perceived influence of
various socio cultural factors such as the media, peers and adult figures regarding
thinness and body ideal. Their disabilities become imperfections. These young women
must also overcome myths that they are asexual or incapable of handling sexual
relationships. Physicians can also reinforce these myths by infantilizing these young
women with physical disabilities well into adulthood though many have aspirations of
marriage and motherhood.
People with disabilities have become increasingly able to live fulfilling lives in
recent decades. This is due largely to studies that have confirmed that once barriers are
264 Nancy Xenakis and Judith Goldberg
addressed and minimized; women with physical disabilities lead active and productive
lives and have much to contribute to society. American with Disabilities Act legislation
has allowed more women with disabilities to enter the mainstream environment socially,
educationally and vocationally. The involvement of professionals, programs and services
assists these women to increase their self-confidence, self-competence and independence.
The Initiative for Women with Disabilities (IWD), a hospital-based center serving
young and adult women with physical disabilities offers accessible gynecology, primary
care, physical therapy, nutrition consultations, exercise and fitness classes, wellness and
social work services and youth based programming. Its mission is to empower women to
pursue a healthy lifestyle.
Keywords: physical disabilities, women, body image, health, wellness.
INTRODUCTION
The myth of bodily perfection, which can be traced back to the Olympians in ancient
Greece, pervades Western culture today (Stone, 1995). The myth posits that human beings
can and should achieve perfect bodies. This is often perpetuated by the media which sends a
powerful message to both men and women emphasizing the importance of the body ideal and
taking responsibility to achieve it (Dunkley, Wertheim, & Paxton, 2001). However, due to
sexism, it is women who are judged and judge themselves by their bodies and are vulnerable
to culturally prescribed appearance norms (Stone, 1995).
P.D. Slade (1994) in his article What is Body Image? describes body image as a loose
mental representation of the body's shape, form and size which is influenced by a variety of
historical, cultural, social, individual and biological factors which operate over varying time
spans. He cautions that professionals need to appreciate the complexity of this when planning
their interventions and research.
Body image in persons with physical disabilities has received minor attention in the
literature even though body image plays a significant role in the lives of persons with
disabilities.
THE INITIATIVE FOR WOMEN WITH DISABILITIES

The Initiative for Women with Disabilities (IWD), a hospital-based center serving young
and adult women with physical disabilities offers accessible gynecology, primary care,
physical therapy, nutrition consultations, exercise and fitness classes, wellness and social
work services and youth based programming. Its mission is to empower women to pursue a
healthy lifestyle.
The IWD develops services/programs based on a social model of disability which infers
that individuals with similar physical disabilities are likely to vary in their feelings and
attitudes towards their own body because of social factors (education, support network and
real and perceived societal attitudes) (Taleporos & McCabe, 2002). Exercise/fitness and
dance classes help the IWD women feel comfortable using their bodies and improve their
physical well-being. In addition to the physical benefits of exercise, there are secondary gains
Body Image in Young and Adult Women with Physical Disabilities 265
that include improvements in the psychological and sociological domains. The World Health
Organization in Health and Development through Physical Activity and Sport (2003)
reports that regular physical activity promotes psychological well-being, reduces stress,
anxiety and depression. Sociological gains include new experiences, new friendships and a
countering of stigmatization for persons with disabilities (Shepard, 1991).
The IWD holds regular beauty workshops that feature make-up, hairstyling and skin care
as outer beauty is important to self-esteem. The women report that these workshops make
them feel more attractive both inside and outside and they learn new ways to take care of
themselves.
The IWD nutritionist teaches group workshops and conducts individual
evaluations/counseling to help the women learn about healthy eating and work on their
personal nutrition goals. The women report that they enjoy learning about general nutrition,
simple ways to develop healthy eating habits and affordable, easy to prepare recipes. The
women seem to develop a higher perceived body image whether it is due to weight loss,
having more energy or taking control of their eating habits in a positive way.
Baylor College of Medicine (2009) cited a study of 31 women with physical disabilities
where for many of them body image appeared to be part of their definition of sexuality or
their view of themselves as attractive sensual women. Women with physical disabilities must
overcome myths that they are asexual or incapable of handling sexual relationships
(Piotrowski & Snell, 2007). Physicians sometimes reinforce these myths by infantilizing these
women with physical disabilities well into adulthood though many have aspirations of
marriage and motherhood. Authors of a 2004 study contend, Birth control and infertility
services are either purposely withheld or simply not considered as necessary or appropriate by
caregivers and healthcare providers (Earle & Church, 2004). The gynecology service at the
IWD recognizes the medical and emotional importance of accessible and appropriate
gynecological care. The women report that they feel respected and are comfortable with the
examination and discussing any issues related to sexual and reproductive health.
Social work services at the IWD focuses on exploration of psychosocial variables that
affects the womens sense of self (body image is often identified) and encourages them to
confront their own judgments and fears through individual and group work. Early
identification and treatment of body image dissatisfaction may help prevent the development
of depression and other psychosocial impairment in women with disabilities (Baylor College
of Medicine, 2009). The presence of depressive disorders often adversely affects the course
and complicates the treatment of chronic disease and conditions. Thus, the promotion of
mental health would likely result in reducing a considerable proportion of the burden of
chronic disability (Chapman, Perry, & Strine, 2005).
The IWD has a mentoring component where IWD members can pair with one of their
peers. This reciprocal relationship, which includes communication by phone, e-mail and in
person, has allowed the women to learn about the social, psychological, physical, educational
and vocational obstacles that exist and how their peers confronted and possibly overcame
them. It fosters a sense of giving back to others and provides an opportunity for the women to
reflect on their own thoughts, beliefs, feelings and actions.
The IWDs various wellness classes (tai chi, acupuncture, massage, Reiki, and
reflexology) introduce the women to complementary medicine modalities as an adjunct to
traditional Western medicine. Often times, women with disabilities are viewed as medical
objects and dissociate from their bodies due to all of the medical interventions they have
266 Nancy Xenakis and Judith Goldberg
experienced. These wellness modalities help them to understand, accept and treat their bodies
in new ways. Many have conveyed that they feel better both physically (decreased pain and
fatigue) and emotionally (decreased feelings of anxiety, depression and helplessness). A
recent national U.S. survey (Carlson & Krahn, 2006) on the use of complementary and
alternative medicine (CAM) treatment among those with a disabling condition suggests that
CAM treatments represent a substantial proportion of the medical care obtained by medically
insured Americans with disabilities.
The IWD also addresses the issue of a visible versus an invisible disability. When a
disability cannot be concealed, for example, a woman using a wheelchair, it leads us to
assume that she cannot use her legs and climb a flight of stairs. It also leads many to believe
that she cannot do anything else either (Stone, 1995). The wheelchair itself, especially the
oversized, motorized chair that has many specialized features to increase comfort and
functionality, seems to create a boundary between the wheelchair user and the rest of society.
Stone (1995) attests that anecdotal evidence suggests that when it is possible to hide a
disability or the full extent of a disability, women are prone to hiding. The IWD does not
want women to hide; it creates a safe place where women can be themselves and be
empowered by other women like them. It creates opportunities for women to assert
themselves to make choices that will improve their lives and become comfortable in their own
bodies.
Acknowledging ones disability does not mean acknowledging ones helplessness, it
means acknowledging and honoring ones humanness (Stone, 1995). At times, there is
reluctance by many of the potential IWD members to joinwomen express that they are not
ready to be formally categorized as a woman with a disability because it makes it too real,
they think they are higher functioning than the other women or they are afraid about the
unknown in confronting their disability. Whatever the reasons may be, the IWD staff listens
to the each womans individual circumstances and helps her to explore its origin and pilot
some of the IWD services/programs that seem to be of interest. The majority of these women
do become active participants in the IWD in their own time.
CONCLUSION
A qualitative study by Taleporos and McCabe (2002) investigated the body image
concerns of persons with disabilities. It indicated that although at some point body image has
been a serious struggle for all, that through the passage of time from disability onset and
positive feedback from close relations, persons with disabilities can achieve a positive body
image, even when it does not duplicate society's image of it. Falvo (2005) suggests that an
increased understanding of chronic illness/disability as an experience rather than a medical
condition can help to decrease discrimination and prejudice that often occur.
At the IWD, this acceptance of one's disability, whether congenital or acquired and the
subsequent development of an improved body image, seems to occur after exposure over time
to IWD services/programs. Some women join the IWD with a relatively positive self-concept
and others are at a stage of denial or self-deprecation. The interaction with IWD medical staff
that promotes wellness and fitness in their practice has a positive influence on body image.
The exposure to peers and mentors, discussion of thoughts and feelings related to one's own
Body Image in Young and Adult Women with Physical Disabilities 267
and societal perception of disability and the process of identifying individual and group
strengths, assists with the eventual transformation to a positive sense of self.
With more than 300 active members, the IWD can conduct qualitative and quantitative
studies exploring body image for women with disabilities across the life span. These studies
would further inform the IWD of how women relate to the issue, assist with the development
of future services/programs to best meet the needs of its members and make some
generalizations for this population that could be beneficial.
REFERENCES
Baylor College of Medicine. Psychosocial health. Retrieved March 16, 2010, from,
http://www.bcm.edu/crowd.
Carlson, MJ., & Krahn, G. (2006). Use of complementary and alternative medicine
practitioners by people with physical disabilities: Estimates from a National US Survey.
Disability and Rehabilitation, 28(8), 505-513.
Chapman, DP., Perry, GS., & Strine, TW. (2005). The vital link between chronic disease and
depressive disorders. Prev Chronic Dis (serial online). Retrieved May 3, 2010, from,
http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm.
Dunkley, TL., Wertheim, EH., & Paxton, SJ. (2001). Examination of a model of multiple
sociocultural influences on adolescent girls body dissatisfaction and dietary restraint.
Adolescence, 36 (142), 265-279.
Earle, S., & Church, S. (2004). Disability and reproduction. Practicing Midwife, 7(8), 32-4.
Falvo, L. (2005). Medical and psychosocial aspects of chronic illness and disability. (4th Ed.).
(pp. 51-64).
Piotrowski, K., & Snell, L. (2007). Health care needs of women with disabilities across the
lifespan. Journal of Obstetric, Gynecologic and Neonatal Nursing, 36(1), 79-87.
Shepard, RJ. (1991). Benefits of sport and physical activity for the disabled: Implications for
the individual and society. Scandanavian Journal of Rehabilitation Medicine, 23(2),51-
59.
Slade, PD. (1994). What is body image? Behav. Res Ther, 32(5), 497-502.
Stone, SD. (1995). The myth of bodily perfection. Disability and Society, 10(4), 413-424.
Taleporos, G., & McCabe, MP. (2002). Body image and physical disability-personal
perspectives. Social Science & Medicine, 54(6), 971-80.
World Health Organization. (2003). Health and Development through Physical Activity and
Sport. Retrieved August 30, 2008, from, http://www.whqlibdoc.who.int/hq/2003/WH
O_NMH_NPH_PAH_03.2.pdf.
Chapter 17
THE NON SATISFIED PATIENT IN AESTHETIC

SURGERY - MEDICAL ATTITUDE
Alberto Rancati1, Maurizio Nava2, Marcelo Irigo3, and

Braulio Peralta4
1
University of Buenos Aires, Universidad Catolica Argentina,
Av. Callao 1046 PB A (1046), Buenos Aires, Argentina
2
Direttore Struttura Complessa di Oncologia Chirurgica
RicostruttivaChirurgia Plastica, Plastic Surgery Unit,
Fondazione IRCCS Istituto Nazionale dei Tumori,
Via Venezian 1, 20133 Milano, Italy
3
Universidad Catolica Argentina,
4
Universidad Catolica Argentina,
ABSTRACT
Usually, patients undergoing plastic surgery have only the expectation of success
about the practice they will undergo, and on the same way, surgeons are prepared and
technically trained to achieve the better result. But what happens when things go wrong?
How can we manage this critical situation where patient receives this bad news and
will probably blame the surgeon for this unexpected outcome?
Elective cosmetic surgery is an increasingly high risk area of medical professional
liability, and, although some claims of negligence associated with elective plastic surgery
are generated because the patient's expectations were not met, others arise from a genuine
adverse outcome where results need revisions, and perhaps surgical planning was not the
best.(1),(2).
1
e-mail: rancati@gmail.com
2
e-mail: maurizio.nava@istitutotumori.mi.it
3
e-mail: irigomarcelo@gmail.com
4
e-mail: braulioperalta@hotmail.com
270 Alberto Rancati, Maurizio Nava, Marcelo Irigo et al.
Unfortunately sometimes this narrow limit between an adverse event and a medical
error is forced to be seen as malpraxis by lawyers, family patients and friends.
INTRODUCTION
How Competent Are Plastic Surgeons in Giving Bad News?
Most plastic surgeons struggle with giving bad news and offer many reasons for avoiding
it:
Lack of training in giving bad news

Fear of being blamed
Fear of emotional reaction
Fear of legal consequences
Breaking bad news is one of physician's most difficult duties; yet medical education
typically offers little formal preparation for this heavy task. Without proper training, the
discomfort and uncertainty associated with breaking bad news may lead physicians to
wrongly take distance from patients, but the way this unexpected bad outcome is
communicated to the patient and family can strongly help in avoiding legal consequences
(3),(4). Giving bad news is stressful for physicians and hearing bad news is difficult for
patients. Yet it is possible to give bad news in a way that creates trust and strengthens the
surgeon-patient relationship.
There are some important events to remark in this stressful situation:
Do Not Delegate Communication of Bad News
Delivering bad news is role of the surgeon, and patients often accept bad news only from
him.
Patients Receiving Bad News May Not Remember Too Much
People who receive bad news may not remember much about the conversation three
months later. In a study carried by Ellen (5), 50% admitted that they took in
little or none of
the information from the initial conversation; 20% didnt remember that a longer information
session had occurred a few days after the initial bad news session; 25% remembered the
information session, but didnt understand the content.
The results of this study indicate that perhaps we may need to have more than one
conversation with the patients or family members before the bad news sinks in. One way to
check on the patients understanding of the news is to ask them to reflect back what they have
heard or what their interpretation of the news is.
The Non-Satisfied Patient in Aesthetic Surgery: Medical Attitude 271
Medical Language Can Make Bad News Worse
A common complicating factor occurs when doctors use medical terminology and
technical language that patients dont understand. This confuses patients and increases their
distress.
Patient and Physician Stress Curve Do Not Match in Time (Fig 1)
At the encounter time, between patient and surgeon, the physician is stressed himself at
the maximum point, for delivering bad news, and this stress decreases for him finalizing the
encounter. For the patient, stress begins at that point, and peaks after the encounter, so, be
prepared to explain everything again, when the patient takes conscious that cosmetic result
was not as planned and will need extra explanation (6). This is the moment where other
players of the conflict appear, i.e., friends, patients couple, lawyers, and why not a dear
colleague.
Ptacek, JAMA 1996: 496-502.
Figure 1.
Patient Perception is What Counts
Patients describe, interpret and judge medical events just based on their own perception,
With all the elements and data presented, the patient will decide after the encounter if remains
with you, runs to a lawyers office or ask for a second opinion with a Colleague, so,
positive or negative impact of the information received, will conduct patients actions
according to HIS/HER reality ,and that cannot match yours.
How a patient responds to bad news can be influenced by the way they are
communicated, not only verbally, but know that the enterprise, body language, voice tone,
and attitude, also counts.
Pitfalls in Giving Bad News
A recent study about the causes of adverse outcomes in cosmetic surgery conducted by
United Medical Protection, the largest medical professional liability insurer in Australia,
observed the following trends associated with adverse outcomes and accompanying litigation
against the surgeon:
Poor physician-patient communication, rather than lack of technical skill or

competence.
Poor patient selection.
Financial considerations. The fact that the patient bears all of the costs of an elective
cosmetic procedure emphasizes the patients expectations and demands as a
customer purchasing a service from the physician.
The patients level of dissatisfaction increased when additional surgeries were
required to achieve a more desirable outcome.
Failure to assess understanding or to acknowledge patient emotions
BAD NEWS STRATEGY

When you notice that an adverse outcome is knocking at the door, anticipate, thats the
moment to decide to share information with your patient, dont let this moment pass through;
confirm medical facts, review relevant clinical data, .arrange adequate time and privacy and
be emotionally prepared for the encounter to make this situation more comfortable for both,
patients and physicians.
1) Create an appropriate physical setting: A quiet, comfortable room, have all

participants, including you sitting down. You can begin with an Unfortunately, Im
afraid the news are not good
2) Avoid being interrupted, do not receive phone calls, turn off your beeper, check your
personal appearance, posture, and keep eye contact. Check distance and how close
you sittoo close may feel intrusive, but too far away may seem unconnected (7).
3) Determine who should be present. Ask the patient whom they want to participate,
clarify who they are. Decide if you want others to be present.
4) Think through your goals for the meeting as well as possible goals of the patient. Be
honest and straight forward about the information to be given; do not doubt that this
information will be checked.
5) Present bad news in a succinct, direct and professional manner. Be prepared to repeat
information and present additional information in response to patient and family
needs.
6) Share all the information you have. Although medical errors do not necessarily
constitute improper, negligent, or unethical behavior, failure to disclose them is all
three. (8)
7) Allow the necessary time to understand the situation. Wait for the patient to respond.
Give an opportunity for questions or comments.
The Non-Satisfied Patient in Aesthetic Surgery: Medical Attitude 273
8) Be prepared to strong reactive emotions like tears, anger, etc. Let the emotions
express and adopt a problem-solving style
9) Awareness to your staff; everybody in your office must give her/him special
attention.
10) Set a probable date for resolution or for achieving the desired final result. Not
managing times may cause more anxiety.
11) Record keeping. Document every picture, what has been said, expectations, names of
present people, dates etc,
12) Contact your legal office to inform about this event Act in advance, and follow the
professional advice, do not wait to contact them until being named in a lawsuit. Hope
for the best but plan for the worst.
CLOSING THE ENCOUNTER

Summarize the main points. Asses understanding
Ask if there is anything further the patient would like to discuss.
Offer assistance to tell others the difficult news.
Indicate your availability to be contacted for questions or concerns.
Offer to get second opinion when appropriate; be conscious of your own limitations.
This requires critical self-awareness
Concrete a follow-up program
CONCLUSION
Focused training in communication skills and techniques to facilitate breaking bad news
has been demonstrated to improve patient satisfaction and physician comfort.
The guidelines suggested are not rules, and they do not ensure a successful end, they
attempt to define principles of practice for providing appropriate care. The ultimate decision
regarding the appropriateness of any strategy must be made by each surgeon in light of all
circumstances.
Giving patients bad news is difficult, and the first time you do it, should not be the first
time you try, getting a chance to practice this strategy and being prepared on how to act
before and unexpected outcome arrives can help surgeons in managing the conflict.
Prevailing in the individual situation and in accordance with the culture, age, relation,
religion, etc. in which the case is rendered.
An important thing to remember in giving bad news is that we cant change the news
itself, but the way they give it can shape the experience for the patient and make a great
difference. We can make the news worse by adding to patient confusion or anxiety, or if well
done, can strength doctor-patient relationship and avoid legal consequences.
NOTE
The authors have no financial disclousures with respect to the content of this article.
REFERENCES
[1] Buckman R. How to break: bad news-A guide for health care professionals. Johns
Hopkins University Press, 1992.
[2] Faulkner A. Breaking bad news - a flow diagram. Palliative Medicine, 1994:8;145-151.
[3] Iverson, VK. Pocket protocols-Notifying survivors about sudden, unexpected deaths.
Galen Press, Inc., Tuscon, Arizona, 1999.
[4] Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA,
157:323, 1996.
[5] Sim, I. How to give bad news. http://www.med.stanford.edu
[6] Eden, Pall Med. 1994: 105-114.
[7] Ptacek, JAMA, 1996: 496-502.
[8] Curtis, J Gen Intern Med. 2001: 41-9.
[9] American College of Physicians: Ethics Manual (Ann Intern Med. 1998) - Ritchie JH,
Davies SC (BMJ 1995).
INDEX
alexithymia, vii, x, 135, 136, 137, 138, 139, 140,

A 141, 142, 143, 146, 147, 148, 149
alienation, 50
Abraham, 36, 43, 44, 45, 54, 257, 260
alopecia, 105, 119
abuse, 2, 4, 131, 258
alternative medicine, 266, 267
accounting, 145
ambivalence, 69, 149
acculturation, 29, 37, 40, 50, 52, 204, 210, 211, 213,
amenorrhea, 258
257, 258
American Psychiatric Association, 75, 82, 98, 99,
accuracy, ix, 57, 59, 60, 61, 69, 70, 73, 75, 76, 78,
151
79, 84, 86, 87, 91, 101, 102, 145, 207, 237, 247,
American Psychological Association, 26, 51, 56, 79,
249
82, 99, 123, 133, 150, 169, 171, 212, 240, 243,
activity level, 216
244, 252
acupuncture, 265
amputation, 175, 184, 186, 187
adaptability, 11
anabolic steroids, 34
adaptation, 8
androgen, 111, 112, 117
adaptations, 249, 250
anemia, 111, 258
adiposity, xii, 111, 157, 216, 218, 221, 222, 227,
anger, 109, 273
231, 233, 237
angina, 209
adjustment, ix, 86, 87, 88, 96, 103, 109, 112, 113,
anorexia, viii, xi, 2, 14, 15, 46, 59, 60, 61, 62, 69, 71,
114, 117, 118, 119
72, 74, 75, 76, 77, 79, 82, 83, 84, 85, 86, 88, 93,
adolescent boys, 24, 25, 33, 34, 53, 55, 56, 85, 102,
94, 98, 99, 100, 101, 102, 136, 139, 140, 141,
168, 169, 170, 228, 229, 241, 242, 243, 252, 261
143, 146, 149, 150, 151, 184, 208, 241, 251, 261
adolescent female, 17, 31, 35, 39, 43, 44, 45, 50, 54,
anorexia nervosa, viii, xi, 2, 14, 15, 59, 60, 61, 62,
55, 86, 241, 242, 260
69, 71, 72, 74, 75, 76, 77, 79, 82, 83, 84, 88, 98,
adulthood, xiv, 63, 185, 222, 224, 229, 263, 265
99, 100, 101, 102, 136, 139, 140, 141, 143, 146,
advantages, 97, 193, 205
149, 150, 151, 184, 208, 241, 251, 261
adverse event, xiv, 270
ANOVA, 161, 193
advertisements, xi, 80, 189, 190, 191, 192, 196, 197,
anthropology, 51
200, 201, 256
anxiety, xi, 2, 8, 10, 12, 13, 65, 66, 68, 70, 106, 110,
advocacy, 132
111, 114, 115, 118, 125, 136, 140, 141, 146, 150,
aerobic exercise, 247
189, 191, 192, 193, 194, 195, 196, 197, 198, 199,
affective dimension, 247
224, 229, 243, 246, 247, 248, 250, 252, 258, 261,
affective experience, x, 121, 132
265, 266, 273
affirming, 116, 126, 127
anxiety disorder, 114
Africa, 41
Argentina, 269
African American women, 38, 211, 212
arousal, 137, 144
African Americans, viii, 28, 39, 40, 42, 49
ASI, 63, 235
AIDS, 205
Asia, 53
Asian countries, 12
276 Index
aspiration, 220 brain, 72, 91, 97, 175, 176, 177, 178, 181, 182, 184,
assessment techniques, 237, 239 187
atherosclerosis, 209 brain activity, 177
athletes, 260 brainstem, 186
atrophy, 110 breast cancer, ix, 103, 105, 106, 107, 112, 117, 118,
attachment, 137 119, 120
attentional bias, ix, 59, 68, 72, 73, 75, 77, 79 breathing, 116
attribution, x, 122, 131, 183 bulimia, 2, 14, 40, 51, 60, 62, 69, 76, 83, 93, 98, 99,
avoidance, 69, 127, 129, 141, 150, 231, 257 101, 139, 140, 141, 143, 149, 150, 168, 170, 207,
avoidance behavior, 141, 257 208, 211, 241, 251, 261
bulimia nervosa, 2, 14, 60, 62, 69, 76, 98, 99, 101,
B 139, 140, 141, 143, 149, 170, 207, 208, 261
Butcher, 148
Bahrain, 257
buttons, 87
barriers, xiii, xiv, 54, 263
beams, 70, 84 C
Beck Depression Inventory, 142, 144
behavioral aspects, 107, 142 calorie, 85
behavioral change, 190 campaigns, 13, 14, 21, 34, 43
behavioral dimension, vii, 82 cancer, vii, ix, x, 103, 104, 105, 106, 107, 108, 109,
behavioral models, 115 110, 111, 112, 113, 114, 115, 116, 117, 118, 119,
behavioral sciences, 168, 199 120, 224
behaviors, xiii, 2, 4, 6, 8, 9, 11, 12, 13, 14, 15, 16, candidates, 141
17, 20, 23, 24, 30, 78, 116, 139, 140, 141, 142, carcinoma, 106
143, 145, 146, 150, 166, 168, 208, 210, 211, 212, cardiovascular disease, 56, 209
231, 235, 240, 242, 246, 255, 256, 258 caregivers, 265
Belgium, 257 categorization, 239
bias, xiii, 69, 70, 71, 72, 73, 75, 76, 77, 78, 79, 90, category a, 17, 219
91, 93, 94, 96, 138, 150, 208, 227, 230, 233, 238, category d, 7
243 Caucasian population, 32, 38, 39, 40
bingeing, 68, 139 Caucasians, viii, 28, 40
Black students, 204 cerebral cortex, 187
BMI, vi, xii, 3, 5, 6, 7, 14, 17, 26, 35, 36, 40, 42, 47, cervical cancer, 109, 110
50, 52, 57, 67, 73, 78, 88, 89, 101, 125, 143, 144, chemotherapy, ix, 103, 105, 106, 108, 109, 110, 112,
145, 146, 191, 192, 193, 195, 198, 203, 204, 205, 115, 117, 119
207, 209, 210, 215, 216, 217, 218, 219, 220, 221, childhood, xii, 21, 25, 32, 35, 54, 118, 174, 175, 215,
222, 224, 238 216, 217, 221, 222, 223, 224, 225, 239
body composition, 23, 30, 52, 237 Chile, 24, 53
body fat, 31, 41, 44, 47, 66, 155, 166, 168, 205, 210, China, 14, 168
233, 235, 238, 257 cholesterol, 111
body mass index, xii, 55, 56, 67, 77, 79, 192, 203, chronic diseases, xii, 203, 205, 209
213, 216, 223, 224, 233, 257 chronic illness, 266, 267
body schema, 186 chronic recurrent, 112
body shape, 5, 6, 7, 14, 18, 19, 20, 31, 35, 38, 41, 43, class, viii, 25, 27, 50, 54, 126, 128, 131, 250, 256,
47, 48, 51, 61, 63, 64, 66, 67, 76, 77, 87, 127, 257
128, 131, 141, 144, 168, 205, 210, 218, 221, 231, clinical disorders, 61
257 clinical psychology, 200
body weight, x, xii, 3, 6, 17, 25, 37, 38, 42, 49, 54, clinical trials, 251
70, 80, 82, 89, 115, 135, 140, 141, 204, 205, 212, close relationships, 139
215, 222, 240, 257, 260 cognition, 98, 136, 200, 232, 241
bone, 125 cognitive activity, 137
bowel, 111, 112 cognitive biases, 142
bradycardia, 15 cognitive capacities, 234
cognitive dimension, 234, 247, 250
Index 277
cognitive dissonance, 198 covering, 84, 129

cognitive process, 62, 64, 84, 91, 139 criticism, 169, 207
cognitive processing, 62, 64, 91, 139 cross-cultural differences, 205
cognitive representations, 230 cross-sectional study, 56, 63
cognitive style, 139 cross-validation, 148
college students, 7, 25, 50, 78, 93, 207, 208, 211 cues, x, 73, 79, 80, 121, 128, 131, 185, 212
colorectal cancer, 112, 113, 119, 120 cultivation, 50
commercials, 236, 241 cultural differences, 6, 7, 53, 205
communication skills, 273 cultural influence, 2, 6, 33, 50, 67, 230
community, 25, 29, 50, 54, 123, 206, 207, 209, 211, cultural norms, xiii, 200, 255
212, 213 cultural practices, 123
comparison task, 193, 199 cultural tradition, 41
complaints, 9 cultural values, 8, 12, 29, 40, 47, 107, 205, 239
complexity, 231, 264 culture, vii, viii, 1, 6, 10, 12, 13, 15, 16, 18, 21, 22,
complications, 119, 258, 261 23, 25, 28, 29, 33, 37, 39, 40, 41, 43, 45, 47, 52,
composition, 23, 30, 52, 68, 76, 157, 237 54, 55, 107, 113, 123, 169, 206, 208, 210, 212,
compulsion, 69 257, 264, 273
compulsive behavior, 140 CVD, 209
computer software, ix, 81, 97
conceptual model, 224, 248 D
conceptualization, 104, 167, 231
data analysis, 156, 167
concordance, 197
data collection, 192, 217, 218
conditioning, 222
data set, 218
conductance, 185
database, 82
conflict, 12, 22, 39, 177, 187, 257, 271, 273
deaths, 105, 274
conformity, 13, 19, 22, 38
decision-making process, 192, 197
confounding variables, 205
deficit, x, 77, 88, 94, 122, 136, 139, 147, 230
confrontation, 101
demand characteristic, 71, 91, 197
congruence, 41, 66
denial, 266
connectivity, 183
Denmark, 257, 260
consciousness, 8, 10, 12, 115, 232
dependent variable, 67, 130, 144, 145, 146, 193, 195,
conservation, 106, 107
208
constipation, 112, 258
depression, xii, 2, 35, 55, 105, 107, 110, 111, 112,
construct validity, 85, 237, 242
114, 115, 116, 122, 125, 131, 136, 140, 142, 147,
consulting, 217
148, 149, 150, 154, 170, 224, 227, 229, 241, 246,
consumption, 13, 39, 53, 77, 123, 124, 125, 134,
252, 265, 266
199, 217
depressive symptoms, 107, 115, 142, 144, 146, 243,
content analysis, 129
252
contour, 89, 232
deprivation, 111, 112, 117
contradiction, 132
desensitization, 116
control condition, 73, 177, 178, 179, 182
designers, 132
control group, 67, 86, 89, 94, 101, 140
detection, ix, 81, 92, 93, 94, 96, 97, 100, 101, 102,
controlled trials, 198
112
coping strategies, 63, 118
developed countries, 43, 257
coronary heart disease, 209
developing nations, 205
correlation, 17, 112, 130, 147, 157, 161, 165, 166,
developmental change, 232
167, 218
deviation, 89, 94, 96, 144, 193
correlation coefficient, 147, 157, 161
DFT, 159, 160
correlations, 84, 86, 94, 130, 138, 157, 161, 165,
diabetes, 42, 45, 49, 205, 209
166, 167
diagnosis, ix, xi, 98, 103, 106, 109, 110, 112, 114,
cortex, xi, 91, 173, 174, 175, 177, 179, 181, 183,
136, 143
184, 185, 186, 187, 188
Diagnostic and Statistical Manual of Mental
counseling, 110, 116, 252, 265
Disorders, 75, 82
278 Index
diagnostic criteria, 21 educational settings, viii, 27

dialogues, 116 Egypt, 107, 257, 261
diarrhea, 112, 258 elaboration, 136
diet, 2, 4, 16, 17, 20, 24, 44, 113, 128, 130, 207, 216, electroencephalography, 183
235, 258 electrolyte, 258
diet pill, 2, 4, 16, 258 electrolyte imbalance, 258
dieting, viii, 2, 4, 5, 6, 8, 11, 12, 14, 16, 17, 18, 20, elementary school, 4, 24, 52
23, 26, 27, 31, 36, 38, 44, 46, 55, 61, 68, 74, 78, emission, 184
127, 142, 154, 200, 207, 212, 228, 229, 239, 242, emotion, 72, 124, 136, 139, 142, 151
247, 251, 258, 260 emotion regulation, 136, 139
difference threshold, 95 emotional conflict, 137
differential diagnosis, 98 emotional distress, 109, 114
direct measure, 89 emotional experience, xi, 124, 136, 139, 142
disability, xiii, 263, 264, 265, 266, 267 emotional information, 137
disappointment, 104, 132 emotional state, xi, 135, 137, 139, 142
discomfort, 109, 110, 112, 270 emotional well-being, 109, 110, 111, 112
discrimination, vii, 27, 56, 96, 266 empathy, xi, 173, 181, 183, 184, 185, 243
disease progression, 108 empirical studies, viii, 59, 60, 139
disorder, xii, 12, 13, 14, 15, 57, 61, 64, 69, 71, 72, employment, 114
74, 76, 79, 82, 83, 87, 88, 89, 93, 96, 98, 99, 100, empowerment, 132
101, 115, 141, 143, 147, 148, 149, 150, 151, 154, energy consumption, 13
169, 170, 203, 208, 209, 224, 233, 241, 249, 251, England, 257, 260
252 enlargement, 111, 178
dissociation, 183 environmental influences, 12
dissonance, 170, 198 epidemic, 216
distortion, vii, viii, ix, 59, 60, 61, 69, 70, 71, 72, 73, equality, 12, 88, 100
74, 75, 76, 77, 78, 80, 81, 82, 83, 84, 85, 86, 87, ethnic background, vii, xii, 27, 203, 204
88, 89, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, ethnic groups, 37, 38, 55, 56, 89, 90
101, 229, 237, 240 ethnic minority, 31, 40, 56
distortions, 60, 63, 70, 71, 72, 73, 74, 76, 85, 86, 87, ethnicity, vii, 1, 2, 6, 15, 25, 37, 38, 43, 50, 53, 54,
92, 100, 184, 229, 237 55, 56, 167, 204, 207, 208, 209, 210, 211, 212,
distress, ix, xi, 24, 60, 103, 106, 107, 108, 109, 110, 248
112, 114, 118, 135, 136, 139, 142, 144, 146, 216, etiology, 23, 40, 51
271 evaluative thought, 231
disturbances, ix, x, xi, 7, 24, 32, 37, 38, 56, 60, 61, evoked potential, 183
75, 85, 98, 100, 102, 103, 104, 105, 106, 107, examinations, 110
111, 112, 113, 114, 115, 116, 136, 143, 149, 151, exclusion, 156, 165
156, 207, 208, 212, 240, 243, 258, 261 execution, 181, 187
diuretic, 4 exercise, vii, xiii, xiv, 2, 6, 15, 17, 20, 23, 25, 35, 36,
divergence, 84 44, 61, 68, 74, 116, 128, 129, 211, 245, 246, 247,
diversity, 32, 34, 250 248, 249, 250, 251, 252, 253, 264
doctors, 137, 271 experiences, x, xi, 2, 4, 5, 16, 17, 51, 68, 72, 78, 113,
dominance, 34, 41, 177 114, 115, 116, 119, 121, 122, 124, 125, 129, 130,
downward comparison, 199 131, 132, 134, 136, 139, 199, 265
drawing, ix, 81, 83, 87, 88, 89, 90, 91, 96, 97, 99, experimental condition, 182
240, 241 exploration, 169, 242, 252, 265
exposure, viii, 11, 26, 29, 32, 51, 59, 60, 64, 67, 73,
E 77, 78, 79, 116, 168, 169, 170, 190, 191, 197,
198, 200, 205, 206, 207, 210, 211, 236, 256, 261,
eating disturbances, 7, 24, 37, 38, 56, 75, 143, 207,
266
208, 212, 243, 258
external environment, 128
ecology, 224
edema, 110
educational programs, 16
Index 279
health care professionals, 114, 274

F health education, 2, 14, 34, 43, 50, 54
health effects, 258
factor analysis, 129, 131, 132, 143, 235
health problems, 2, 14, 16, 49, 142, 246, 258
fairy-tales, 174
health status, 50, 110
family members, 21, 29, 270
heart attack, 209
fantasy, 66, 136, 138
heart disease, 209
fat, 4, 5, 6, 8, 17, 18, 19, 20, 21, 23, 30, 31, 35, 36,
heart failure, 209
41, 44, 45, 46, 47, 49, 61, 66, 72, 82, 126, 127,
height, 6, 7, 19, 34, 44, 76, 77, 78, 86, 89, 129, 143,
155, 166, 168, 205, 210, 228, 229, 233, 234, 235,
168, 174, 192, 217, 223
236, 238, 243, 244, 257, 258
helplessness, 266
fears, 141, 228, 265
hemiplegia, 86
feedback, viii, 28, 32, 33, 35, 59, 60, 64, 65, 66, 67,
heroism, 36
68, 74, 78, 266
heterogeneity, 90, 208
feedback conditions, 66
high blood pressure, 209
feelings, vii, ix, 28, 29, 34, 61, 81, 82, 104, 106, 113,
high school, 4, 16, 17, 20, 24, 207
115, 116, 124, 125, 132, 136, 137, 138, 139, 140,
Hispanics, 38, 40
142, 144, 146, 174, 185, 187, 190, 197, 204, 228,
historical overview, ix, 81, 96
231, 234, 237, 247, 257, 264, 265, 266
HIV, 205
femininity, 107, 109
HIV/AIDS, 205
fertility, 45, 109, 110
homogeneity, 128, 147, 161
Fiji, 34, 39, 41, 42, 50, 53, 55
Hong Kong, 12, 14, 53
fitness, xiv, 17, 34, 41, 246, 250, 264, 266
hopelessness, 113
five-factor model, 148
hospitalization, 13, 62, 83
fluctuations, 20, 62, 64
human brain, 187
fluid, 128, 131
human subjects, 177
Ford, 207, 211
Hunter, 86, 99, 117
France, v, 135, 257
hyperactivity, 139
functional changes, 108, 111
hypertension, 205
G hypothesis, xi, 37, 42, 67, 71, 80, 142, 146, 153, 171,
176, 177, 196
gel, 198 hysterectomy, 109, 110
gender differences, xii, 7, 25, 44, 46, 47, 70, 75, 86,
I
211, 227, 244
gender equality, 12
ideals, xiii, 12, 22, 23, 25, 28, 29, 31, 32, 35, 36, 37,
gender role, xiii, 10, 12, 18, 34, 232, 243, 256, 263
38, 41, 43, 47, 50, 51, 53, 55, 64, 65, 66, 122,
general practitioner, 224
123, 129, 166, 167, 169, 198, 205, 206, 228, 231,
genes, 42
236, 255, 256, 257, 263
genetics, 243
idiosyncratic, 143
genotype, 54
illusion, 177, 178, 179, 180, 185, 186
Georgia, 261
illusions, xi, 173, 177, 178, 179, 184
Germany, 173, 257
imagery, 32, 33, 50, 72, 75, 87, 116
globalization, 257
imagination, 62, 183, 186
group therapy, 150
imitation, 186, 187
group work, 265
impacts, 108, 248
guessing, 70, 78
impairments, 106
guidelines, 31, 273
implicit association test, 241
H Implicit Association Test, 236
implicit memory, 236
hair, ix, 103, 105, 106, 114, 115, 131, 206, 210 in vivo, 61, 62
hair loss, ix, 103, 105, 106, 114, 115 incidence, xii, 7, 23, 215, 216
happiness, 205 independence, xiv, 157, 264
head and neck cancer, 108, 109, 117, 118, 119 independent variable, 130, 145, 146, 193
280 Index
indirect effect, 209 legislation, xiv, 264

indirect measure, 236 leisure, 133
individual differences, 72, 191, 241, 250 leisure time, 133
individuality, 257 lens, 85
Indonesia, 41 lifestyle changes, 222
induction, 62, 63 lifetime, 63
industrialized countries, 113 light beam, 84, 91, 102
inferences, 181 Limitations, 231
infertility, 105, 110, 265 linear function, 125
Information Technology, 100 literacy, 34, 132
infrastructure, 131, 132 litigation, 272
initial state, 131 locus, 102
inoculation, 116 longitudinal study, 50, 52, 54, 88, 99, 100, 151, 168,
insecurity, 140 169, 241
integration, 50, 177, 178, 179 lymph, 109
intentionality, 183 lymph node, 109
interaction effect, 193, 195, 196 lymphedema, 110, 119
internal consistency, 157, 234, 235, 236, 238, 249,
250 M
internalised, x, 122, 128
magazines, x, 9, 11, 64, 79, 121, 123, 130, 132, 134,
internalization, xi, 10, 143, 153, 154, 155, 156, 157,
168, 169, 192, 196, 197, 200, 241, 256
161, 162, 165, 166, 168, 169, 171, 199, 200, 206,
magnetic resonance, 177
210, 230, 261
magnetic resonance imaging, 177
internalizing, 34, 206
magnetoencephalography, 176, 186
Internet, 211
major depression, 140, 147, 148
interpersonal events, 116
majority, 30, 32, 42, 43, 45, 49, 64, 123, 124, 126,
intervention, xiii, 29, 45, 105, 119, 132, 198, 210,
132, 154, 167, 196, 204, 221, 222, 229, 239, 250,
212, 222, 247, 248, 249, 250, 252, 255
266
introspection, 236
mammalian brain, 175
Iran, 260
management, 63, 70, 75, 78, 109, 111, 117, 122, 124,
Ireland, 50, 227
142, 225, 256
Israel, 138
manipulation, 73, 87, 101, 193, 194, 195, 197, 217,
Italy, 135, 257, 269
249, 251
J manufacture, 129, 133
marital status, 145, 205
Japan, v, vii, 1, 2, 6, 8, 10, 11, 12, 13, 14, 15, 16, 18, marketing, 124, 196
19, 20, 21, 22, 23, 24, 25 marriage, xiv, 263, 265
Japanese women, 2, 7, 12, 13, 23, 26 masculinity, 19, 23
job performance, 105 mass media, xiii, 33, 64, 66, 67, 190, 255, 256, 257,
Jordan, 255, 257, 261 258
junior high school, 16, 17 mastectomy, 106, 107
justification, 92 matrix, 129, 241
media messages, 32, 256, 257, 258
K median, 89, 200
mediation, 12, 246
Korea, 14
medical care, 266
L Mediterranean, 261
MEG, 176, 177, 179
lack of control, 139 memory, 72, 73, 87, 181, 185, 188, 230, 231, 236
lawyers, xiv, 270, 271 memory capacity, 231
laxatives, 15, 16, 208, 209, 258 menarche, 44, 257, 260
learning, 116, 222, 265 menopause, 109, 110
Lebanon, 260 mental disorder, 2, 13, 98, 151
Index 281
mental health, vii, 27, 77, 106, 265 negativity, 144

mental image, 72, 73, 75 neglect, 38, 229
mental imagery, 72, 75 negotiating, 50, 131, 132
mental representation, 42, 72, 237, 264 nervous system, 175
messages, x, 21, 29, 32, 33, 34, 37, 44, 48, 52, 122, Netherlands, 189
123, 132, 133, 169, 207, 212, 222, 230, 235, 256, neural connection, 175
257, 258, 261 neural network, 183
meta-analysis, xi, 83, 98, 101, 153, 155, 165, 166, neurobiology, 136
167, 168, 169, 208, 212, 247, 250, 251, 252, 253 neuroimaging, 187
metabolic syndrome, 20, 21, 211 neuropsychology, 147
metamorphosis, 174 neuroscience, 73, 75
metaphor, 174 New Zealand, 31, 36, 41, 53, 57, 224
metastatic disease, 112 non-clinical population, 73
methodology, xi, 79, 83, 86, 92, 94, 129, 153, 155, normal children, 242
156, 157, 161, 205, 239, 251 North America, 50, 76, 211, 245
Middle East, 45, 47, 48, 49, 107 Norway, 31, 257
migrants, 43 nurses, 109
minority groups, 31, 37, 38, 239 nursing, 117
modeling, 21 nutrition, xiv, 216, 224, 264, 265
modelling, 44
moderates, 251 O
moderators, xii, 167, 199, 203, 210, 246, 250
OAS, 138
modern society, 42
obesity, vii, xii, 13, 14, 16, 22, 25, 26, 27, 42, 45, 46,
modernization, 22
47, 48, 49, 51, 53, 54, 55, 57, 72, 76, 79, 85, 99,
monitoring, 12, 116
102, 115, 142, 205, 209, 211, 212, 215, 216, 217,
mood swings, 141
221, 222, 223, 224, 225, 240, 243, 244, 260
morbidity, ix, 103, 108, 110, 111, 113, 117
obesity prevention, 22, 47, 51, 222, 224
motivation, 91, 141
objectification, 122, 123, 134, 170
motor actions, 187
obsessive-compulsive disorder, 147, 148
motor system, 178
obstacles, 265
MRI, 177
old age, 185
multiculturalism, 37
one dimension, 205, 248
multidimensional, x, 74, 82, 135, 140, 167, 169, 241,
opportunities, 266
251
organ, ix, 103, 108, 111
muscle mass, 44, 111
organizing, 181
muscle relaxation, 116
oscillations, 186
muscles, 33, 48, 68, 166
osteoporosis, 111
music, 64, 116, 123
outpatients, 147, 148, 149
music videos, 64
ovarian cancer, 117
N ovaries, 109, 110
overlap, 62
national character, 22 overlay, 84
National Survey, 30 overweight adults, vii, 27
Native Americans, 40
nausea, 105, 112 P
neck cancer, 108, 109, 117, 118, 119
Pacific, viii, 26, 28, 41, 42, 45, 47, 48, 49, 53, 57
negative attitudes, 107
Pacific Islanders, 57
negative consequences, 43, 198, 210
pain, 109, 110, 176, 185, 186, 187, 266
negative experiences, x, 113, 122, 124
panic disorder, 147, 148
negative feedback, 65
paralysis, 86
negative mood, 62, 126
parental influence, 170, 242
negative outcomes, 216, 229
parental pressure, 258
negative relation, 208
282 Index
parietal cortex, 181, 183, 184 prejudice, 36, 266

parietal lobe, 178, 184 preschool, 238
pathogenesis, 76, 142 preschool children, 238
pathology, xii, 29, 37, 40, 52, 82, 83, 96, 125, 143, preschoolers, 225
151, 170, 171, 227, 229, 261 prestige, 39
pathways, 22, 167, 169, 228, 241 prevention, 2, 22, 25, 26, 32, 43, 47, 51, 52, 54, 57,
peer group, 32, 232 99, 116, 167, 170, 200, 212, 217, 221, 222, 223,
peer influence, viii, 8, 11, 23, 28, 201 224, 240, 243, 244
percentile, 145, 233 primary school, 47
perceptual component, ix, 81, 82, 91, 95, 96, 99, 229, primate, 186
240 prioritizing, 225
perceptual sensitivity, 91, 94 probability, 143
perfectionism, 52, 63, 169 probe, 72
performance, 34, 41, 96, 105, 122, 134, 154, 181, problem-solving, 273
252, 258 processing deficits, 149
permission, iv, 95, 97, 220, 250 profit, 198
personal choice, 126 prognosis, 114
personal computers, 86 programming, xiv, 207, 264
personal identity, xi, 130, 173 project, 87, 223
personality characteristics, 71, 112 promotion campaigns, 13
personality disorder, 140 proposition, 122, 129
personality factors, 91 prosperity, 39, 45
persons with disabilities, 264, 265, 266 prostate cancer, 105, 111, 112, 117, 118, 119, 120
Perth, 215, 217, 224 prostatectomy, 117
PET, 184, 186, 187 prostheses, 104
phantom limb pain, 175, 176, 186 prosthesis, 114
pharmacotherapy, 136 protective factors, 204
phobia, 8, 13 psychiatric disorders, 114, 136
photographs, ix, 68, 71, 74, 81, 87, 218 psychiatric morbidity, ix, 103
physical activity, 17, 18, 20, 53, 54, 55, 222, 223, psychological distress, ix, xi, 103, 106, 110, 112,
225, 251, 265, 267 118, 135, 136, 139, 144, 146, 216
physical attractiveness, 18, 22, 201, 212 psychological health, 200, 246
physical education, 54 psychological problems, 260
physical fitness, 246 psychological states, 104
physical health, 21, 33 psychological variables, 167
physical therapist, 114 psychological well-being, 110, 209, 211, 252, 265
physical therapy, xiv, 264 psychology, viii, ix, 24, 59, 60, 74, 81, 134, 170,
physical well-being, 264 199, 200, 248, 252
physiological factors, 28 psychometric function, 94, 96, 102
plastic surgeon, 270 psychometric properties, 89, 90, 97, 167, 238, 249,
plasticity, 186 250
pleasure, x, 116, 122 psychopathology, 72, 78, 82, 139, 147, 148, 149,
polarization, 14 151, 244
population group, 49 psychophysics, 92, 93
portraits, 256 psychosocial dysfunction, 109
positive correlation, 130 psychosocial functioning, 51, 235
positive feedback, 35, 67, 266 psychosomatic, 136, 147
positive mood, 62 psychotherapy, 116, 136, 148, 149
positive relationship, xiii, 64, 208, 245 pubertal development, 31, 54, 231
positron, 184 puberty, 23, 31, 43, 45, 46, 47, 51, 56, 231, 232, 256,
positron emission tomography, 184 257
postmenopausal women, 107 public health, 2, 21
preadolescents, 26, 200, 233, 235, 244 public policy, 222
Index 283
resistance, 60, 69
Q resolution, 273
resources, 250
Qatar, 257
responsiveness, 249
qualitative research, x, 121
restructuring, 116
quality assurance, 133
retail, 126, 132
quality of life, x, 103, 106, 108, 109, 110, 111, 112,
risk factors, 10, 32, 37, 143, 150, 168, 222, 224, 258
113, 114, 115, 117, 118, 119, 120, 212, 251
rods, 84
quartile, 46
Rosenberg Self-Esteem Scale, 142
questioning, 109
Royal Society, 76, 212
R rubber, 179
S
race, 50, 53, 204, 205, 210, 211
racial differences, 204
sadness, 109
racism, 210
sampling error, 209, 210
radiation, ix, 103, 105, 110, 117
Saudi Arabia, 257
Radiation, 105
scars, ix, 103, 105, 106, 110, 112, 114
radiation therapy, ix, 103, 110, 117
schema, 141, 186, 230, 236, 239, 241, 242
radical mastectomy, 107
schizophrenia, 85
radiotherapy, 106, 108, 109, 111, 112, 118
schooling, 228
rating scale, xiii, 129, 138, 144, 151, 205, 210, 227,
screening, 46, 125, 222, 224
232, 233, 234, 237
self esteem, viii, 12, 27, 54
rationalisation, 129
self-awareness, 273
reaction time, 72, 236
self-concept, 53, 54, 56, 64, 75, 104, 107, 143, 256,
reactions, 28, 105, 168, 199, 236
258, 266
reading, 64, 68, 75, 130, 174, 217, 236, 256
self-confidence, xiv, 264
reading skills, 217
self-consciousness, 115, 232
reality, 128, 131, 174, 247, 271
self-control, 21
recall, 207
self-discrepancy, ix, 103, 104
receptive field, 183
self-efficacy, 212, 246
recognition, x, 6, 26, 61, 101, 121, 181, 186, 187,
self-enhancement, 78, 191, 197, 198
216, 222, 234, 248
self-identity, 184
recommendations, iv, 82, 161, 222
self-image, 107, 110, 116, 200, 261
reconstruction, 106, 107, 110, 118, 119
self-improvement, 191, 199
reflexivity, 124
self-monitoring, 116
regression, 130, 142, 144, 145, 146, 193, 195
self-perceptions, 28, 104, 190, 228, 252
regression analysis, 142, 144, 145, 146, 193, 195
self-promotion, 12
regression equation, 195
self-reflection, 124
regression model, 144
self-worth, x, 63, 104, 115, 135, 140, 170, 256, 257
rehabilitation, 114, 118
semi-structured interviews, 61, 125
rehabilitation program, 114
sensation, 177, 178, 186
relationship satisfaction, 107
sensations, xi, 91, 135, 136, 137, 139, 144, 148, 175,
relaxation, 116
177, 178, 179, 185, 187
relevance, ix, 41, 81, 99, 136
senses, 177, 187
reliability, 61, 84, 85, 86, 89, 90, 97, 99, 101, 112,
sensitivity, 78, 80, 91, 93, 94, 95, 96, 101, 170, 174,
125, 129, 130, 137, 138, 148, 157, 233, 234, 235,
230
236, 237, 238, 239, 243, 249
serum, 147
reliability values, 84, 86
SES, vi, 45, 47, 48, 142, 205, 209, 215, 216, 217,
replication, 26, 78, 90
221
reproduction, 267
sex, 52, 66, 155, 204, 212, 248
resection, 108, 112, 113
sexism, 264
reserves, 39
sexual health, 110
residuals, 146
284 Index
sexuality, x, 103, 106, 109, 110, 112, 113, 114, 118, starvation, 39, 139
123, 167, 232, 265 statistics, 144
shame, 122, 256, 261 stereotypes, 46, 236
short-term memory, 181 stereotyping, 171, 225
side effects, 105, 110, 111, 112, 114, 116, 209 steroids, 34, 229, 235
signal detection theory, ix, 81, 92, 96, 97 stigmatized, vii, 27, 208
signals, 137, 185 stimulus, 91, 93, 94, 96, 177, 181
signs, 185 stoma, 112, 113, 114, 117
SII, 178, 183, 185, 187 stomach, 17, 73, 193
silhouette, 66, 87, 88, 89, 101, 232 subgroups, 26, 57, 157
simulation, 186 substance abuse, 258
Singapore, 14 substance use, 61, 148
skills training, 115 succession, 86
skin, 106, 114, 177, 185, 206, 210, 212, 265 suicide, 30, 208, 212
smoking, 61, 246 supervision, 216
social acceptance, 256 survey, 7, 11, 14, 23, 53, 119, 129, 150, 204, 205,
social anxiety, 8, 10, 12, 13, 115 207, 223, 224, 260, 266
social change, 50 survival, 42, 105, 111, 112
social class, 25, 54, 256, 257 survival rate, 105, 111, 112
social cognition, 185 survivors, 106, 110, 111, 112, 118, 119, 274
social comparison, 10, 64, 80, 129, 169, 190, 199, susceptibility, 198
200, 201, 206, 243 Sweden, 257
social comparison theory, 190, 206 Switzerland, 257
social context, 166 symptomology, 170, 233
social desirability, 137, 138 symptoms, xii, 11, 12, 15, 40, 85, 106, 107, 109,
social environment, 38 110, 111, 115, 118, 136, 141, 142, 144, 146, 148,
social identity, 123 168, 169, 170, 200, 203, 208, 209, 243, 252, 260,
social influence, 65, 155, 169 261
social influences, 155, 169 syndrome, 20, 21, 187, 211
social network, 23
social norms, viii, 13, 59, 60, 72, 132 T
social perception, xi, 173, 187, 222
tactile stimuli, 175, 177
social problems, 125
Taiwan, 3, 14, 106, 118
social psychology, 199
teenage girls, 17, 229, 236
social relations, 130, 136
television commercial, 236, 241
social relationships, 130, 136
testing, 96, 141, 144, 170, 196, 198, 201, 242, 248
social situations, 140, 183, 185, 193
testosterone, 111
social skills, 115
test-retest reliability, 85, 90, 233, 234, 235, 236, 237
social skills training, 115
TF, 117, 118, 150, 151
social status, 38
thalamus, 179, 185
social support, 108, 110, 118
theatre, 114, 134
social transition, 231
theoretical assumptions, 198
social withdrawal, 112
therapeutic approaches, 184
socioeconomic status, 32, 45, 46, 54, 56, 205, 216,
therapy, ix, xiv, 103, 106, 107, 108, 110, 111, 112,
224, 257
115, 116, 117, 118, 126, 150, 264
software, ix, 70, 81, 86, 87, 88, 89, 96, 97, 99
thin body ideals, 38
South Africa, 205
thoughts, ix, 28, 29, 36, 72, 81, 82, 115, 127, 174,
South Pacific, 41
197, 228, 231, 247, 265, 266
Spain, 101
threats, 71
spinal cord, 247, 250, 252
three-way interaction, 198
spinal cord injury, 247, 250, 252
tissue, 106
standard deviation, 89, 94, 96, 144, 193, 194
tofu, 15
standard error, 161
Tonga, 34, 41, 42, 53, 55
Index 285
toys, 36, 55 visual processing, 94

tracks, 84 visual stimuli, 181
traditional gender role, 10, 18 visual stimulus, 181
traditional views, 178 visual system, 91, 97
traditions, 22, 41, 107 vomiting, 15, 31, 105, 112, 139, 142, 258
training, 116, 170, 235, 248, 250, 251, 252, 270, 273 vulnerability, 35, 40, 231, 235, 241
Trait Anxiety Scale, 144, 193, 200 vulnerability to depression, 35, 241
traits, 12, 56, 141
transactions, 131 W
transcripts, 125, 129
waking, 174
transformation, 161, 267
weakness, 258
trial, 92, 93, 119, 170, 252
wealth, 205
Turkey, 103, 105, 107
wear, 122, 126, 127, 130
type 2 diabetes, 45, 209
websites, 34
U weight control, 7, 26, 31, 32, 43, 44, 45, 46, 47, 54,
57, 68, 89, 141, 170, 207, 224
UK, 31, 118, 147, 158 weight gain, ix, 13, 35, 44, 45, 48, 54, 55, 62, 68, 69,
Ukraine, 168, 240 72, 103, 106, 110, 111, 223, 228
underlying mechanisms, 192 weight loss, ix, 7, 16, 25, 30, 33, 38, 39, 44, 45, 46,
uniform, 112 55, 78, 85, 103, 104, 112, 210, 228, 233, 238,
United Arab Emirates, 257, 260 247, 265
United Kingdom, 31, 252 weight management, 142
upward comparisons, 198 weight reduction, 85, 100, 102, 241
weight status, 216, 221, 223, 224
V welfare, 198
wellness, xiii, xiv, 263, 264, 265, 266
vagina, 109, 110
Western countries, vii, 1, 6, 7, 10, 14, 15, 19, 21, 41,
validation, 76, 99, 100, 102, 117, 147, 148, 151, 171,
42, 43, 221
200, 232, 240, 241, 244, 250, 251
valuation, 151 Y
variations, 50, 63, 141
video, 64, 83, 86, 87, 89, 91, 93, 95, 97, 99, 101, yes/no, 234
177, 179, 180, 181, 229, 237 young adults, 2, 4, 13, 26, 30, 32, 36, 43, 75
vision, 177, 181, 185, 186 young women, x, xiv, 7, 22, 25, 31, 35, 43, 45, 50,
visual attention, 77, 78 62, 64, 69, 76, 78, 106, 117, 121, 125, 127, 129,
visual modality, 177 130, 131, 132, 134, 190, 191, 198, 256, 263

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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

BODY IMAGE: PERCEPTIONS,

BODY IMAGE: PERCEPTIONS,

Nova Science Publishers, Inc.

NOTICE TO THE READER

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Published by Nova Science Publishers, Inc. New York

Chapter 10 Nothing Compares to You: The Influence of Body Size of Models

Body image is considered a multi-dimensional concept that includes perceptual,

AN HISTORICAL PERSPECTIVE OF BODY IMAGE AND

Naomi Chisuwa1 and Jennifer A. ODea2*

BODY IMAGE DISTURBANCE

BODY IMAGE STUDIES IN JAPAN

Wardle et al. (18,512 17-30 Perception of being overweight and

Study Sample Age Major findings

Nakamura et al. 406 27.9 (mean) 42.4% (dieting experiences), 5.9%

Study Sample Age Major findings

COMPARATIVE STUDIES ABOUT BODY IMAGE DISTURBANCE

Study Sample Age Major findings

Study Sample Age Major findings

FACTORS ASSOCIATED WITH BODY IMAGE DISTURBANCE AND

OBESITY IN JAPAN AS AN INFLUENCE ON BODY IMAGE

EATING DISORDERS IN JAPAN

EARLY REPORTS OF EATING DISORDERS FROM JAPAN

RESEARCH IN THE LATE 20TH CENTURY

DISORDERED EATING BEHAVIORS IN JAPAN

RECENT FINDINGS FROM QUALITATIVE INTERVIEWS WITH YOUNG

Body Image in Females

Specific cultural references were not mentioned however during interviews as

Body Image in Males

In regard to height concerns, or wanting to be taller, Japanese males were similar to

Body Image in Japanese Society

BODY IMAGE AMONG ABORIGINAL CHILDREN AND

Renata L. Cinelli and Jennifer A. ODea*

t he multifaceted psychological experience of embodiment, especially but not

Body dissatisfaction is defined as:

BODY IMAGE AMONG ADOLESCENTS IN WESTERN COUNTRIES

SOCIO-CULTURAL INFLUENCES ON ADOLESCENTS BODY IMAGE

YOUNG CHILDREN MALES AND FEMALES

BODY IMAGE AMONG DIFFERENT ETHNIC GROUPS

African American Adolescents

BODY IMAGE RESEARCH FROM NON WESTERN COUNTRIES

BODY IMAGE RESEARCH IN AUSTRALIA

BODY IMAGE IN AUSTRALIAN ADOLESCENTS

BODY IMAGE RESEARCH AMONG CHILDREN

Study Sample Age Major findings

Study Sample Age Major findings

Table 2. A summary of body image research conducted among Aboriginal Australian

Mellor, 47 12-16 Males place more consequence on muscle size and

BODY IMAGE RESEARCH RELATED TO ABORIGINAL

Mussap, A. J. (2009). Acculturation, body image, and eating behaviours in Muslim-

THE PSYCHOLOGY OF BODY IMAGE:

Jennifer S. Mills, Kaley Roosen and Rachel Vella-Zarb

THE MEANING AND MEASUREMENT OF BODY IMAGE

BODY IMAGE ASSESSMENT

BODY IMAGE VARIABILITY

SOCIAL AND CULTURAL INFLUENCES ON BODY IMAGE

Exposure to Media Images

Correlational studies have consistently shown a positive relationship between naturally-

BODY IMAGE INSTABILITY: CAUSE OR EFFECT OF

BODY IMAGE ACCURACY

of psychological research, we then turn to individual difference variables as possible

PERCEPTUAL ASPECTS OF BODY IMAGE

weight reasonably accurately. It is more likely that weight underestimation represents a